ASSOCIATE ABSTRACTS 2012 - American College of Physicians

ASSOCIATE ABSTRACTS 2012
1

Table of Contents
ASSOCIATE RESEARCH PODIUM PRESENTATIONS ...................................................................................... 24
HAWAII PODIUM PRESENTATION - RESEARCH Kei Sonoda, MD ............................................................ 25
ILLINOIS PODIUM PRESENTATION - RESEARCH Rojina Pant, MBBS ....................................................... 26
MICHIGAN PODIUM PRESENTATION - RESEARCH Tezo Anto Karedan, MD ........................................... 27
MINNESOTA PODIUM PRESENTATION - RESEARCH Melissa A Wells, MD ............................................. 28
NEVADA PODIUM PRESENTATION - RESEARCH Ramesh Keerthi Gadam, MBBS ................................... 29
NEW HAMPSHIRE PODIUM PRESENTATION - RESEARCH David Nagel, MD ........................................... 30
NEW YORK PODIUM PRESENTATION - RESEARCH Dany A Raad, MD ..................................................... 31
OHIO PODIUM PRESENTATION - RESEARCH Georges Nakhoul, MD ...................................................... 32
PENNSYLVANIA PODIUM PRESENTATION - RESEARCH Julian Nahuel Diaz Fraga, MD ........................... 33
PENNSYLVANIA PODIUM PRESENTATION - RESEARCH Nimesh K Patel, MD.......................................... 34
ASSOCIATE RESEARCH POSTER FINALISTS .................................................................................................. 35
ARIZONA POSTER FINALIST - RESEARCH Nduka-Obi F Ossai, MBBS ....................................................... 36
ARKANSAS POSTER FINALIST - RESEARCH Sadip Pant, MBBS ................................................................. 37
CANADA POSTER FINALIST - RESEARCH George Ou, MD ........................................................................ 38
CALIFORNIA POSTER FINALIST - RESEARCH Vincent Kao, DO ................................................................. 39
CALIFORNIA POSTER FINALIST - RESEARCH Theresa L Nilson, MD ......................................................... 40
CALIFORNIA POSTER FINALIST - RESEARCH Patrick S Lin, MD PhD ......................................................... 41
CALIFORNIA POSTER FINALIST - RESEARCH Benton T Ashlock, MD ........................................................ 42
CALIFORNIA POSTER FINALIST - RESEARCH Lueng Tcheung, MD ........................................................... 43
CALIFORNIA POSTER FINALIST - RESEARCH Susan Wong, MD ................................................................ 44
CALIFORNIA POSTER FINALIST - RESEARCH Ajay Yadlapati, MD ............................................................. 45
CANADA POSTER FINALIST - RESEARCH Ashraf M Al Azzoni, MBBS ....................................................... 46
COLORADO POSTER FINALIST - RESEARCH Alison R Landrey, MD .......................................................... 47
CONNECTICUT POSTER FINALIST - RESEARCH Olivia Pop, MD ............................................................... 48
2

Chile POSTER FINALIST - RESEARCH Maria M Canals Cavagnaro, MD .................................................... 49
CONNECTICUT POSTER FINALIST - RESEARCH Aroonsiri Sangarlangkarn, MD ....................................... 50
DELAWARE POSTER FINALIST - RESEARCH Chia-Shing Yang, MD ........................................................... 51
DELAWARE POSTER FINALIST - RESEARCH Chia-Shing Yang, MD ........................................................... 52
DISTRICT OF COLUMBIA POSTER FINALIST - RESEARCH Stephen Koplin ................................................ 53
FLORIDA POSTER FINALIST - RESEARCH Marlow B Hernandez, DO ........................................................ 54
FLORIDA POSTER FINALIST - RESEARCH Abubakr A Chaudhry, MD ........................................................ 55
FLORIDA POSTER FINALIST - RESEARCH Elizabeth Marsicano, MD......................................................... 56
GEORGIA POSTER FINALIST - RESEARCH Zahi Mitri, MD ........................................................................ 57
GEORGIA POSTER FINALIST - RESEARCH Vimal Ramjee, MD .................................................................. 58
US ARMY POSTER FINALIST - RESEARCH CPT Amy N Stratton, DO ......................................................... 59
ILLINOIS POSTER FINALIST - RESEARCH Jennie H Kwon, DO ................................................................... 60
ILLINOIS POSTER FINALIST - RESEARCH Trinadha Pilla, MBBS ................................................................ 61
ILLINOIS POSTER FINALIST - RESEARCH Prantesh Jain, MD .................................................................... 62
ILLINOIS POSTER FINALIST - RESEARCH Kiran Narreddy, MBBS .............................................................. 63
ILLINOIS POSTER FINALIST - RESEARCH Vijaya Sivalingam Ramalingam, MD ......................................... 64
ILLINOIS POSTER FINALIST - RESEARCH Sangeetha Reddy...................................................................... 66
KENTUCKY POSTER FINALIST - RESEARCH Thorsten M Leucker, MD ...................................................... 67
MARYLAND POSTER FINALIST - RESEARCH Mohit Girotra, MBBS .......................................................... 68
MARYLAND POSTER FINALIST - RESEARCH CPT Johnny A Dias, MC USA ................................................ 69
MARYLAND POSTER FINALIST - RESEARCH Katrina A Abadilla, MD ........................................................ 70
MARYLAND POSTER FINALIST - RESEARCH Subhash Chandra, MD ........................................................ 71
MARYLAND POSTER FINALIST - RESEARCH CPT Johnny A Dias, MC USA ................................................ 72
MARYLAND POSTER FINALIST - RESEARCH Dhavalkumar Patel, MBBS .................................................. 73
MASSACHUSETTS POSTER FINALIST - RESEARCH Aparna Raj, MD ......................................................... 74
3

MASSACHUSETTS POSTER FINALIST - RESEARCH Shihab Masrur ........................................................... 75
MASSACHUSETTS POSTER FINALIST - RESEARCH Sandeep R Somalaraju, MBBS ................................... 77
MICHIGAN POSTER FINALIST - RESEARCH Mostafa O El-Refai, MBBCH ................................................. 78
MICHIGAN POSTER FINALIST - RESEARCH Shwan Mohamod Ohahir Jalal, MBChB ............................... 79
MICHIGAN POSTER FINALIST - RESEARCH Raid Ahmad Abu-Awwad, MD .............................................. 80
MICHIGAN POSTER FINALIST - RESEARCH Mohammed N Kanaan, MBBS .............................................. 81
MICHIGAN POSTER FINALIST - RESEARCH Javier Neyra, MD .................................................................. 82
MICHIGAN POSTER FINALIST - RESEARCH Hussein Othman, MD ........................................................... 83
MICHIGAN POSTER FINALIST - RESEARCH Anuradha Poolla, MD, MPH ................................................. 84
MICHIGAN POSTER FINALIST - RESEARCH Vidushi Sharma, MD ............................................................. 85
MINNESOTA POSTER FINALIST - RESEARCH Ben Y Zhang, MD ............................................................... 86
MINNESOTA POSTER FINALIST - RESEARCH Kristina Krohn, MD ............................................................ 87
MINNESOTA POSTER FINALIST - RESEARCH Evan L Hardegree, MD ....................................................... 88
MISSISSIPPI POSTER FINALIST - RESEARCH Sushant Khaire, MBBS ........................................................ 89
MISSISSIPPI POSTER FINALIST - RESEARCH Arnaldo Lopez-Ruiz, MD ..................................................... 90
MISSISSIPPI POSTER FINALIST - RESEARCH Dominique J Pepper, MD .................................................... 91
MISSISSIPPI POSTER FINALIST - RESEARCH Licy L. Yanes Cardozo, MD .................................................. 92
MISSOURI POSTER FINALIST - RESEARCH Delene P Etwaru, MD ............................................................ 93
MISSOURI POSTER FINALIST - RESEARCH Mayank K Mittal, MD ............................................................ 94
NEBRASKA POSTER FINALIST - RESEARCH Swati Prasad, MBBS.............................................................. 95
NEBRASKA POSTER FINALIST - RESEARCH Subhankar Chakraborty, MD ................................................ 96
NEW JERSEY POSTER FINALIST - RESEARCH Hao Zhang, MD .................................................................. 97
NEW JERSEY POSTER FINALIST - RESEARCH Sreelatha Naik, MD ............................................................ 98
NEW JERSEY POSTER FINALIST - RESEARCH jennifer c kam, md ........................................................... 100
NEW JERSEY POSTER FINALIST - RESEARCH Mujtaba Hasnain, MD ...................................................... 101
4

NEW JERSEY POSTER FINALIST - RESEARCH Hari Om Sharma, MD ....................................................... 102
NEW YORK POSTER FINALIST - RESEARCH Eric J Berkowitz, MD .......................................................... 103
NEW YORK POSTER FINALIST - RESEARCH Elena Katz, MD ................................................................... 104
NEW YORK POSTER FINALIST - RESEARCH Jaxel Lopez Sepulveda, MD ................................................ 105
NEW YORK POSTER FINALIST - RESEARCH Rakesh Malhotra, MD MPH ............................................... 106
NEW YORK POSTER FINALIST - RESEARCH Suchita J Mehta, MBBS ...................................................... 107
NEW YORK POSTER FINALIST - RESEARCH Girish N Nadkarni MD, MPH, CPH ...................................... 109
NEW YORK POSTER FINALIST - RESEARCH Gopichand Pendurti, MBBS ............................................... 110
NEW YORK POSTER FINALIST - RESEARCH Aye Myat Myat Saw, MD ................................................... 111
NEW YORK POSTER FINALIST - RESEARCH Hemant Sindhu, MD .......................................................... 112
NEW YORK POSTER FINALIST - RESEARCH Atsushi Sorita, MD ............................................................. 113
NEW YORK POSTER FINALIST - RESEARCH Ehtesham Ul Haq, MBBS .................................................... 114
NEW YORK POSTER FINALIST - RESEARCH Xi Zheng, MD, PhD ............................................................. 115
NEW YORK POSTER FINALIST - RESEARCH Dean Padavan, MD ............................................................ 117
OHIO POSTER FINALIST - RESEARCH Yun Xia, MD ................................................................................. 118
OHIO POSTER FINALIST - RESEARCH Ahmed M Ibrahim, MD ............................................................... 119
OHIO POSTER FINALIST - RESEARCH Ali Raza, MD ................................................................................ 120
OHIO POSTER FINALIST - RESEARCH Shoshana Jo Weiner, MD ............................................................ 121
OKLAHOMA POSTER FINALIST - RESEARCH Howard Y Lee, DO ............................................................ 122
OKLAHOMA POSTER FINALIST - RESEARCH Jason Shultz, MD .............................................................. 123
OKLAHOMA POSTER FINALIST - RESEARCH Vishal Mundra, MD .......................................................... 124
OKLAHOMA POSTER FINALIST - RESEARCH Vishal Mundra, MD .......................................................... 125
OREGON POSTER FINALIST - RESEARCH Jonathan Rogers, MD ............................................................ 126
PENNSYLVANIA POSTER FINALIST - RESEARCH Val Rakita, MD ............................................................ 127
PENNSYLVANIA POSTER FINALIST - RESEARCH Julian Manuel Diaz Fraga, MD .................................... 128
5

PENNSYLVANIA POSTER FINALIST - RESEARCH Joy L Montes, MD ....................................................... 129
PENNSYLVANIA POSTER FINALIST - RESEARCH Chathur Acharya, MD ................................................. 130
PENNSYLVANIA POSTER FINALIST - RESEARCH Ravi K Sharma, MBBS.................................................. 131
PENNSYLVANIA POSTER FINALIST - RESEARCH Abhishek Biswas, MBBS .............................................. 132
PENNSYLVANIA POSTER FINALIST - RESEARCH Leena Jalota, MD ........................................................ 133
PENNSYLVANIA POSTER FINALIST - RESEARCH Keyur K Mavani, MBBS ............................................... 134
PENNSYLVANIA POSTER FINALIST - RESEARCH Ryan Arthur McConnell, MD....................................... 135
PENNSYLVANIA POSTER FINALIST - RESEARCH Parit Mekaroonkamol, MD ......................................... 136
PENNSYLVANIA POSTER FINALIST - RESEARCH Eva Tseng, MD ............................................................ 137
SAUDI ARABIA POSTER FINALIST - RESEARCH Mohammad Al Mansour .............................................. 138
SAUDI ARABIA POSTER FINALIST - RESEARCH Arif Abdul Hak .............................................................. 139
SAUDI ARABIA POSTER FINALIST - RESEARCH Zianab Al Duhailib ........................................................ 140
SOUTH CAROLINA POSTER FINALIST - RESEARCH Elmira Basaly, MD ................................................... 141
SOUTH CAROLINA POSTER FINALIST - RESEARCH Fatima Cody Stanford, MD, MPH ........................... 142
TENNESSEE POSTER FINALIST - RESEARCH Muhammad U Khan, MBBS ............................................... 143
TENNESSEE POSTER FINALIST - RESEARCH Muhammad U Khan, MBBS ............................................... 144
TENNESSEE POSTER FINALIST - RESEARCH Owaisur Rahman, MD ....................................................... 145
TEXAS POSTER FINALIST - RESEARCH Farshad Forouzandeh, MD ........................................................ 146
TEXAS POSTER FINALIST - RESEARCH Gurjot Kaur Basra, MBBS ........................................................... 147
TEXAS POSTER FINALIST - RESEARCH Samir J Patel, MD ....................................................................... 148
TEXAS POSTER FINALIST - RESEARCH Alejandro Velasco, MD .............................................................. 149
USAF POSTER FINALIST - RESEARCH CPT KELVIN BUSH, MC, USAF ...................................................... 150
US ARMY POSTER FINALIST - RESEARCH CPT HILLARY THOMAS, MC USA ........................................... 151
US ARMY POSTER FINALIST - RESEARCH CPT Sherrell T Lam, MD ........................................................ 152
USAF POSTER FINALIST - RESEARCH John Paul Magulick, Jr MD .......................................................... 153
6

US NAVY POSTER FINALIST - RESEARCH Brent Wallace Lacey, MD ...................................................... 154
VERMONT POSTER FINALIST - RESEARCH Justin M Stinnett-Donnelly, MD ......................................... 155
VIRGINIA POSTER FINALIST - RESEARCH Armin Rashidi, MD ................................................................ 156
WEST VIRGINIA POSTER FINALIST - RESEARCH William Aaron Hood, DO ............................................ 157
WEST VIRGINIA POSTER FINALIST - RESEARCH Cynthia E Collins, DO .................................................. 158
WEST VIRGINIA POSTER FINALIST - RESEARCH Adam H Maghrabi, MD ............................................... 159
WISCONSIN POSTER FINALIST - RESEARCH Dajun Wang, MD .............................................................. 160
ASSOCIATE VIGNETTE PODIUM PRESENTATIONS .................................................................................... 161
CALIFORNIA PODIUM PRESENTATION - CLINICAL VIGNETTE Maria E Andrae-Hammond, MD ........... 162
FLORIDA PODIUM PRESENTATION - CLINICAL VIGNETTE Andrew D Timothy, DO ............................... 163
ILLINOIS PODIUM PRESENTATION - CLINICAL VIGNETTE Mudita Bhugra, MBBS ................................. 164
ILLINOIS PODIUM PRESENTATION - CLINICAL VIGNETTE Emad Uddin Abdul Samad hakemi, MD ...... 165
MASSACHUSETTS PODIUM PRESENTATION - CLINICAL VIGNETTE Rattanaporn Mahatanan, MD ...... 166
NEW YORK PODIUM PRESENTATION - CLINICAL VIGNETTE Syeda A Batul, MBBS ............................... 168
PENNSYLVANIA PODIUM PRESENTATION - CLINICAL VIGNETTE Dhavalkumar P Sureja, MBBS .......... 169
PUERTO RICO PODIUM PRESENTATION - CLINICAL VIGNETTE Cristy Gianna Martinez, MD ............... 170
TEXAS PODIUM PRESENTATION - CLINICAL VIGNETTE Richard Wayne Hilliard, Jr DO ......................... 171
VIRGINIA PODIUM PRESENTATION - CLINICAL VIGNETTE Vince Faridani, MD ..................................... 172
ASSOCIATE VIGNETTE POSTER FINALISTS ................................................................................................ 173
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Sheela Subramanyam, MD ................................... 174
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Phillip K Henderson, DO ....................................... 176
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Nicholas L Sparacino, DO ....................................... 177
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Peter V Cherian, MD............................................... 178
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Lillian Y Hsu, MD ................................................ 179
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Rekha A Kumbla, MD ......................................... 180
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Jaimeet S Chhabra, DO ...................................... 181
7

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Stacy H Shoshan, MD......................................... 182
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Janet J Abou, MD ............................................... 183
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Maria E Andrae-Hammond, MD ........................ 184
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Swapna P Busa, MBBS ....................................... 185
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE David J Cho, MD................................................. 186
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Allison S DeKosky, MD ....................................... 187
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Paul Di Capua, MD MBA .................................... 188
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Renea Jablonski, MD ......................................... 189
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Amirkaveh Mojtahed, MD ................................. 190
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Nima Naimi, DO ................................................. 191
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Sajan Patel, MD ................................................. 192
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Rena H Shah, MD ............................................... 193
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Alisson D Sombredero, MD ............................... 194
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Sowmya P Srinivasan, MD ................................. 195
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Ajay Yadlapati, MD ............................................ 196
CANADA POSTER FINALIST - CLINICAL VIGNETTE Stephanid Dizon, MBChB ........................................ 197
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Andrew John Sweatt, MD ................................... 198
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Jodie A Barr, DO ................................................. 199
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Ryan Borne, MD ................................................. 200
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Christopher B Estopinal, MD .............................. 201
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Shai Feingold, DO ............................................... 202
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Jonathan Schwartz, MD ...................................... 203
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Amy M Silverberg, MD ....................................... 204
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Keith Wells, MD .................................................. 205
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Chi Zheng, MD .................................................... 206
8

CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Shireen Mirza, MD ......................................... 207
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Vasanth Kainkaryam, MD .............................. 208
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Zhongzhen Li, MD .......................................... 209
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Muhammad Adnan Sohail, MBBS ................. 210
DELAWARE POSTER FINALIST - CLINICAL VIGNETTE Jennifer A Hurd, MD ........................................... 211
DELAWARE POSTER FINALIST - CLINICAL VIGNETTE Christopher J Prendergast, MD........................... 212
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Lara M Paraskos, MD .............................................. 214
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Ricardo Correa, MD ................................................. 215
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Ricardo Correa, MD ................................................. 216
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE David Franco, MD .................................................... 217
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Morganna L Freeman-Keller, DO ............................ 218
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Shenoda Gadalla, MD ............................................. 219
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Natallia Maroz, MD ................................................. 220
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Laurie Ann Ramrattan, MD ..................................... 221
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Anusha Vallurupalli, MBBS ...................................... 222
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Mary T Oluwatimilehin, MD ................................... 223
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Mahmoud Abdou, MD ........................................... 224
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Kamiran Jafar, MD.................................................. 225
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Robert D Kung, MD ................................................ 226
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Scheherezada Urban, MD ...................................... 227
HAWAII POSTER FINALIST - CLINICAL VIGNETTE Ekamol Tantisattamo, MD ........................................ 228
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Vijaya Sivalingam Ramalingam, MBBS ..................... 229
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jeffrey R Borgeson, MD ........................................... 230
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Ayokunle Temidayo Abegunde, MBBS .................... 231
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kumar Kunnal Batra, MD ......................................... 232
9

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Stephen A Boateng, DO ........................................... 233
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kalyani Chandra ....................................................... 234
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jatin Chhabra, MD ................................................... 235
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jatin Chhabra, MD ................................................... 236
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Swapna Devanna, MBBS .......................................... 237
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Deepa Dharanipragada, MBBS ................................ 238
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kinza Gul M.D; ......................................................... 239
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Samrina Hassan, MBBS ............................................ 240
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Prantesh Jain, MD .................................................... 241
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Adrienne N Kovalsky, DO ......................................... 242
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Geeta Kutty, MD ...................................................... 243
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kiran Narreddy, MD ................................................. 244
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Ahmet Afsin Oktay, MD ........................................... 245
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Tarpan R Patel, MD .................................................. 246
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Nilofar Rahman, MBBS ............................................ 247
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Nilofar Rahman, MBBS ............................................ 248
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Manish P Shrestha, MD ........................................... 249
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Abhijai Singh, MD .................................................... 250
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Naykky Maruquel Singh Ospina, MD ....................... 251
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Soujanya sodavarapu, MD ....................................... 252
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muhammad Toor, MBBS ......................................... 253
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muhammad Toor, MBBS ......................................... 254
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Malvika Varma, MD ................................................. 255
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Rahul Wadke, MBBS ................................................ 256
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muralidhar Reddy Yerramadha, MD ....................... 257
10

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Ben A Tritle, MD ...................................................... 258
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Jacques R Daoud, MD ............................................. 259
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Joseph Khalil, MD .................................................... 260
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Kapil A Mehta, MD .................................................. 261
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Matthew M Nobari, MD ......................................... 262
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Andrew J Williams, MD ........................................... 263
IOWA POSTER FINALIST - CLINICAL VIGNETTE Nicholas L Hartog, MD ................................................. 264
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Karim Richard Masri, MD ......................................... 265
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Samuel Kilaho Akidiva, MD ...................................... 266
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Anup Kumar Kasi Loknath Kumar, MBBS ................. 267
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Sapna A Shah-Haque, MD ........................................ 268
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Neil E Crittenden, MD .......................................... 269
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Ziad A Taimeh, MD............................................... 270
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Shilpa Gadde, MD................................................ 271
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Justin D Fowlkes, MD .......................................... 272
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Christian Mabry, MD ........................................... 273
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Christian Mabry, MD ........................................... 274
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Abhishek Seth, MD .............................................. 275
MAINE POSTER FINALIST - CLINICAL VIGNETTE Karen Elizabeth Bascom, MD ..................................... 276
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Tanyaporn Wansom, MD MPP ........................... 277
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Kathy L McGill, DO .............................................. 278
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Shan Shan Chen, MD .......................................... 279
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Stefan David, MD ............................................... 280
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Ezza Aslam Khan, MBBS ..................................... 281
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Nyan L Latt, MD .................................................. 282
11

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Hui Peng, MD ..................................................... 283
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Abdulghani Saadi, MD ........................................ 284
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Sunita Sharma, MBBS ......................................... 285
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Namita Singh, MD .............................................. 286
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Uday Chintamani Lele, MD ....................... 287
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Denisa Bellani, DO .................................... 288
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Anju Bhagavan, MD .................................. 289
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Shihab Masrur........................................... 290
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Vinod Mohan, MD .................................... 291
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Owolabi Ogunneye, MD, MRCP ................ 292
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Owolabi Ogunneye, MD, MRCP ................ 293
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Atul Vijay Palkar, MD ................................ 294
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Srijana Ranjit, MD ..................................... 295
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Renee K Rutledge, MD .............................. 296
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Praveen Sudhindra, MBBS ........................ 297
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Cristina T De Castro-Dela Cruz, MD ..................... 298
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Mershed Alsamara, MD ....................................... 299
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE In Chul An, DO ..................................................... 300
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Subramanyeswara Rao Arekapudi, MD ............... 301
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Amal Ashraf, MD .................................................. 302
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Quratulain Aziz, MBBS ......................................... 303
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Pavan Kumar Bhamidipati, MD ........................... 304
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Pavan Kumar Bhamidipati, MD ........................... 305
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Somy S George, MD ............................................. 306
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Salwa Hussain, MBBS ........................................... 307
12

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Salwa Hussain, MBBS ........................................... 308
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Mayuri Sunil Jagirdar, MD ................................... 309
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Shwan Mohamod Dhahir Jalal, MBChB ............... 310
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Joe Marie Jose-Dizon, MD ................................... 311
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Zaid Kasmikha, DO ............................................... 312
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Eve E Kenfack, MD ............................................... 313
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tejaswini Kulkami, MD MPH ............................... 314
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Navneet Kumar, MD ............................................ 315
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Leonardo E Lopez, Jr MD ..................................... 316
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ridhwi Mukerji, MD ............................................. 317
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ridhwi Mukerji, MD ............................................. 318
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Praneet K Nanduri, MD ........................................ 319
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Monzer Saad, D.O ................................................ 320
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tiffany Sanford, MD ............................................. 321
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aubrey N Schmidt, MD ........................................ 322
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ankur Sharma, MD .............................................. 323
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aruna Vommi, MD ............................................... 324
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Jessie Roske, MD ............................................... 325
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Muaz M Abudiab, MD ....................................... 326
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Elena N Kazimirko, MD ..................................... 327
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Mary C Drinane, MBChB ................................... 328
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Evan L Hardegree, MD ...................................... 329
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Livia L Hegerova, MD ........................................ 330
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Shiao Yen Khoo, MD ......................................... 331
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Ammar M Killu, MBBS ....................................... 332
13

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Yoel Korenfeld, MD ........................................... 333
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Nicole M Loo, MD ............................................. 334
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Jasmine R Marcelin, MD ................................... 335
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Eric M Nelsen, MD ............................................ 336
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Darrell B Newman, MD ..................................... 337
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Sandeep M Patel, MD ....................................... 338
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Sandeep M Patel, MD ....................................... 339
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Chaithra Prasad, MD ......................................... 340
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE David Raslau, MD .............................................. 341
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE John T Ratelle, MD ............................................ 342
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Julio C Sartori-Valinotti, MD ............................. 343
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Julio C Sartori-Valinotti, MD ............................. 344
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Joseph H Skalski, MD ........................................ 345
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Eoin R Storan, MBChB ....................................... 346
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Karna K Sundsted, MD ...................................... 347
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Hemang Yadav, MBBS ....................................... 348
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Cory B Carter, MD .............................................. 349
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Daniel Robert Hatcher, DO ................................. 350
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Dane Ballard ....................................................... 351
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Alycia Cleinman, MD .......................................... 352
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Sushant Khaire, MBBS ........................................ 353
MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Sanjay H Maniar, MD ............................................ 354
MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Sina Jasim, MD ...................................................... 355
MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Anilkumar Katta, MD ............................................ 356
NEVADA POSTER FINALIST - CLINICAL VIGNETTE Dinadelle B Viola, MD.............................................. 357
14

NEVADA POSTER FINALIST - CLINICAL VIGNETTE Jason W Suszko, MD ................................................ 358
NEVADA POSTER FINALIST - CLINICAL VIGNETTE Reza Vaghefi-Hosseini, MD ..................................... 359
NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE William A Hammond, MD ......................... 360
NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE Sung-hee Choi, MD ................................... 362
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Nayan K Desai, MD ............................................ 363
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Parag A Chevli, MD ............................................ 364
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Tatiana Gandrabura, MD .................................. 365
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Tatiana Gandrabura, MD .................................. 366
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vipin Mittal, MBBS ............................................ 367
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vipin Mittal, MBBS ............................................ 368
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Ronald E Pachon, MD ........................................ 369
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Imran A Shaikh, MD .......................................... 370
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Imran A Shaikh, MD .......................................... 371
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Yue Cindy Wang ................................................ 372
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Sumeja Zahirovic, MD ....................................... 373
NEW MEXICO POSTER FINALIST - CLINICAL VIGNETTE Jonathan Jivin Danaraj, DO ............................. 374
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Cesar Esteban Ayala-Rodriguez, MD ................... 375
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Suneesh C Anand, MBBS ..................................... 377
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Saeed Ahmed, MBBS ........................................... 378
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nischala Ammannagari, MBBS ............................ 379
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Narender Annapureddy MD ................................ 380
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Narender Annapureddy MD ................................ 381
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nidhi Bansal, MBBS ............................................. 382
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Ruthie May U Chua, MD ...................................... 383
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Karen de Castro Dah, MD .................................... 384
15

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Amishi Desai, MBBS............................................. 385
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Christopher Dittus, DO ........................................ 386
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Shira B Eytan, MD ................................................ 387
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Christos Fountzilas, MD ....................................... 388
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sharon George MD .............................................. 389
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Robert J Gianotti III ............................................. 390
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Arun Gopal, MD ................................................... 391
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Vanya Grover, DO ................................................ 392
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jehad M Haggiagi, MD ......................................... 393
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Stephan Heo ........................................................ 394
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Elena Katz, MD .................................................... 396
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jehanzeb Khan, MBBS ......................................... 397
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Hina Khan, MD .................................................... 398
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sharad Kothari, MD ............................................. 399
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Grace N LaTorre, DO ........................................... 400
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Philippe Leveille .................................................. 401
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Vivek A Lingiah, MD............................................. 402
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Akshiv Malhotra, MBBS ....................................... 403
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Akshiv Malhotra, MBBS ....................................... 404
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sandhya Manohar, MD ....................................... 405
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sandhya Manohar, MD ....................................... 406
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Maryah Mansoor ................................................. 407
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Maryah Mansoor ................................................. 408
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Carlos Martinez-Balzano, MD ............................. 409
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Carlos Martinez-Balzano, MD ............................. 410
16

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Asad Mohammad, DO ......................................... 411
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jose E Najul .......................................................... 412
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Olabimpe Solape Omobomi, MBChB .................. 413
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Pramod Pantangi, MD ......................................... 414
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Resmi Premji, MD ................................................ 415
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Ameer Z Rasheed, MD ......................................... 416
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jharendra P Rijal, MBBS ...................................... 417
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Muniba Rizvi, MD ................................................ 418
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nishtha Sareen, MD ............................................ 419
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Gayathri Sathiyamoorthy, MD ............................ 420
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sunny Shah, MD .................................................. 421
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Tulsi Sharma, MBBS............................................. 422
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Tulsi Sharma, MBBS............................................. 423
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Yahuza Siba, MD .................................................. 424
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Hemant Sindhu, MD ............................................ 425
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Deepthi Sara Sony, MD ....................................... 426
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Yuzhu Tang, MD .................................................. 427
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Pallawi Torka, MD ............................................... 428
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nay Min Tun, MD ................................................ 429
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jose A Villamil, MD .............................................. 430
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Mehran Yaghmaie ............................................... 431
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jun Zhang, MD PhD ............................................. 432
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Heather B Friedman, MD ......................... 433
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Suheir Khajuria, MD ................................. 434
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Ross M Nesbit, MD .................................. 435
17

NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Megha Sawhney, MBBS ........................... 436
OHIO POSTER FINALIST - CLINICAL VIGNETTE Kanchan V Landge, MD ................................................ 437
OHIO POSTER FINALIST - CLINICAL VIGNETTE Shubhi Agrawal, MD ..................................................... 438
OHIO POSTER FINALIST - CLINICAL VIGNETTE Abidemi Bobby Akande, MD ........................................ 439
OHIO POSTER FINALIST - CLINICAL VIGNETTE Sado Al Bitar, M.D. ....................................................... 440
OHIO POSTER FINALIST - CLINICAL VIGNETTE Rasha Al-Bawardy, MD ................................................. 441
OHIO POSTER FINALIST - CLINICAL VIGNETTE S Bajaj Navkaranbir, MD ............................................... 442
OHIO POSTER FINALIST - CLINICAL VIGNETTE Muhammad Bawany, MD ............................................ 443
OHIO POSTER FINALIST - CLINICAL VIGNETTE Keaton M Bullen, DO .................................................... 444
OHIO POSTER FINALIST - CLINICAL VIGNETTE Sriranjini Chilkunda Ramaswamy, MD ......................... 445
OHIO POSTER FINALIST - CLINICAL VIGNETTE Ayham Deeb, MD ......................................................... 446
OHIO POSTER FINALIST - CLINICAL VIGNETTE Dheeraj Goyal, MD, MPH ............................................. 447
OHIO POSTER FINALIST - CLINICAL VIGNETTE Ismail Hader, MD .......................................................... 448
OHIO POSTER FINALIST - CLINICAL VIGNETTE Serge Harb, MD ............................................................ 449
OHIO POSTER FINALIST - CLINICAL VIGNETTE Ahmed M Ibrahim, MD ................................................ 450
OHIO POSTER FINALIST - CLINICAL VIGNETTE Owais M Idris, MD ........................................................ 451
OHIO POSTER FINALIST - CLINICAL VIGNETTE Owais M Idris, MD ........................................................ 452
OHIO POSTER FINALIST - CLINICAL VIGNETTE Kalipraveena NV Iruku, MD .......................................... 453
OHIO POSTER FINALIST - CLINICAL VIGNETTE Navjot Kaur, MD ........................................................... 454
OHIO POSTER FINALIST - CLINICAL VIGNETTE Yun Hui Lee, MD ........................................................... 455
OHIO POSTER FINALIST - CLINICAL VIGNETTE Maroun Matta, MD ...................................................... 456
OHIO POSTER FINALIST - CLINICAL VIGNETTE Mustafa Musleh, MD.................................................... 457
OHIO POSTER FINALIST - CLINICAL VIGNETTE Chithra Poongkunran, MBBS ........................................ 458
OHIO POSTER FINALIST - CLINICAL VIGNETTE William C Schnackel, MD .............................................. 459
OHIO POSTER FINALIST - CLINICAL VIGNETTE Patrice Scipio, MD MPH ............................................... 460
18

OHIO POSTER FINALIST - CLINICAL VIGNETTE Raja K Singh, MBBS ....................................................... 461
OHIO POSTER FINALIST - CLINICAL VIGNETTE Brett C Sklaw, MD ........................................................ 462
OHIO POSTER FINALIST - CLINICAL VIGNETTE Ryan Patrick Spilman, DO ............................................. 463
OHIO POSTER FINALIST - CLINICAL VIGNETTE Swapna Thota, MD ....................................................... 464
OHIO POSTER FINALIST - CLINICAL VIGNETTE Azadeh Toofaninejad, DO............................................. 465
OHIO POSTER FINALIST - CLINICAL VIGNETTE Bill C Tran, MD .............................................................. 466
OHIO POSTER FINALIST - CLINICAL VIGNETTE Amy Vizcarra, DO ......................................................... 467
OHIO POSTER FINALIST - CLINICAL VIGNETTE Zhenchao Wang, MD .................................................... 468
OHIO POSTER FINALIST - CLINICAL VIGNETTE Muhammad Ahsan Zafar, MD ...................................... 469
OKLAHOMA POSTER FINALIST - CLINICAL VIGNETTE Bhavin C Patel, MD ............................................ 470
OREGON POSTER FINALIST - CLINICAL VIGNETTE Kate S Gustafson, MD ............................................. 471
OREGON POSTER FINALIST - CLINICAL VIGNETTE Kristina L Bajema, MD ............................................ 472
OREGON POSTER FINALIST - CLINICAL VIGNETTE Christopher A March, MD ....................................... 473
OREGON POSTER FINALIST - CLINICAL VIGNETTE Jesus A Moreno, MD ............................................... 474
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Sara Hanna, MBBCH ..................................... 475
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Anna Kaminsky, DO ...................................... 476
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aurangzeb Baber, MD .................................. 477
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aurangzeb Baber, MD .................................. 478
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Swapna Reddy Bemalgi, MD ........................ 479
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Monodeep Biswas, MD ................................ 480
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Monodeep Biswas, MD ................................ 481
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jincy Clement, MD ....................................... 482
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Julian Manuel Diaz Fraga, MD ...................... 483
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Zakiya V Douglas, MD .................................. 484
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Donny V Huynh, MD .................................... 485
19

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ruchika Kazi, MD .......................................... 486
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Haseeb A Kazi, MD ....................................... 487
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ryan Arthur McConnell, MD ........................ 488
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Bonita A Mohamed, MD .............................. 489
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Juhi Moon, MD ............................................. 490
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ji Hyun Rhee, MD ......................................... 491
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ji Hyun Rhee, MD ......................................... 492
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Shamsuddin Shaik, MBBS ............................. 493
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Shailendra Singh, MD ................................... 494
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Daniel John Spinuzzi, MD MBA .................... 495
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Daniel John Spinuzzi, MD MBA .................... 496
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Matthew J Stanishewski, DO ........................ 497
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Rashmi V Thatte, MBBS ............................... 498
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jayaram R Thimmapuram, MBBS ................. 499
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aubre A Weber, DO ..................................... 500
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Zhineng Jayson Yang, MD ............................ 501
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Julio J Valentin, MD ......................................... 502
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Maryknoll De La Paz, MD ................................ 503
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Victor J Mariano, MD ...................................... 504
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Azar Sadeghalvad, MD .................................... 505
RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Ross W Hilliard, MD ...................................... 506
RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Elizabeth Ko, MD .......................................... 507
RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Michele Therese L Yamamoto, MD .............. 508
SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Ashley N Latos, MD .................................. 509
SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Nathan Richards, MD ............................... 510
20

SOUTH DAKOTA POSTER FINALIST - CLINICAL VIGNETTE Muhammad A Khan, MD ............................ 511
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Ahmad Lutfi Alazzeh, MD ................................... 512
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Matthew Erickson Edwards, DO ......................... 513
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Hetvi K Joshi, MD ................................................ 514
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Adrianne C Netterville, MD ................................ 515
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Pranav B Patel, MD ............................................. 516
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Devon Paul, MD .................................................. 517
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Tejas Vinodbhai Raiyani, MD .............................. 518
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Gaurav S Shah ..................................................... 519
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Gaurav S Shah ..................................................... 520
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Michael J McNeal, MD ................................................ 521
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Linh M Lu, DO .............................................................. 522
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Salman Jamaluddin Bandeali, MBBS ........................... 523
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Niru Cepeda-Iruegas, MD ........................................... 524
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Cindy Douglas, MD ...................................................... 525
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Jennifer Lynne Jarvie ................................................... 526
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Myung Sun Kim, MD ................................................... 527
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Manuel Lopez Vazquez, MD ....................................... 528
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Kamil Muhyieddeen, MD ............................................ 529
TEXAS POSTER FINALIST - CLINICAL VIGNETTE CPT Stephen J Park, MC USAF ..................................... 530
USAF POSTER FINALIST - CLINICAL VIGNETTE CPT Frederic A Rawlins, III DO ...................................... 531
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Charlene A Vestermark Gibb, DO ................... 532
UTAH POSTER FINALIST - CLINICAL VIGNETTE Sonja Raaum, MD ........................................................ 533
USAF POSTER FINALIST - CLINICAL VIGNETTE Adam L Ackerman, MD ................................................. 535
USAF POSTER FINALIST - CLINICAL VIGNETTE Sabrina M Sumner, DO ................................................. 536
21

US ARMY POSTER FINALIST - CLINICAL VIGNETTE Meredith A Hays, DO ............................................. 537
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Amy N Stratton, DO ........................................ 538
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Aaron Walter Pumerantz, DO ......................... 539
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Brian Joseph Stout, MD.......................................... 540
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Pamela S Meyers, MC USA .............................. 541
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Vanya Wagler, DO ........................................... 542
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Vanya Wagler, DO ........................................... 543
US NAVY POSTER FINALIST - CLINICAL VIGNETTE Caitlin M O'Connor, MD ......................................... 544
US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Geoffrey J Cole, MD ........................................... 545
US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Priti Nath, MD .................................................... 546
US NAVY POSTER FINALIST - CLINICAL VIGNETTE Edward Thomas Stickle, Jr MD ............................... 547
US NAVY POSTER FINALIST - CLINICAL VIGNETTE Eric T Meek, MD ..................................................... 548
US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Haydar M Al-Eid, MD .......................................... 549
US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Michael James E Monson, DO MA ..................... 550
UTAH POSTER FINALIST - CLINICAL VIGNETTE Craig D Robison ............................................................ 551
VERMONT POSTER FINALIST - CLINICAL VIGNETTE Mitchell L Nimmich, MD ...................................... 552
VERMONT POSTER FINALIST - CLINICAL VIGNETTE Elizabeth B Nimmich, MD .................................... 553
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Vince Faridani, MD ................................................. 554
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE LT Manoj Mathew, MD .......................................... 555
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Sandra Moallem, MD ............................................. 556
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Bonny Lauren Moore, MD ...................................... 558
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Seth T Parsons, MD ................................................ 559
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Chhayaben V Patel, MBBS ...................................... 560
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Om Samantray, MD ................................................ 561
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kristyn M Sayball, DO ............................................. 562
22

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kristyn M Sayball, DO ............................................. 563
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kenneth Surkin, MD ............................................... 564
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Janki Shah, MD ....................................................... 565
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Angela D Venuto-Ashton, MD ................................ 566
WASHINGTON POSTER FINALIST - CLINICAL VIGNETTE Julie B Silverman, MD .................................... 567
WASHINGTON POSTER FINALIST - CLINICAL VIGNETTE Sarah Anne Buckley, MD ............................... 568
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Abdel Rahman M Lataifeh, MD .................... 569
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Dheeraj Kodali, MD ...................................... 570
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Deepa R Ovian, MBBS ........................................ 571
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Asma Arayan, MD .............................................. 572
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Tessa W Damm, DO ........................................... 573
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Zouyan Lu, MD ................................................... 574
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Christiane N Mbianda, MD ................................ 575
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Jessica L White, MD ........................................... 576
23

ASSOCIATE RESEARCH PODIUM PRESENTATIONS
24

HAWAII PODIUM PRESENTATION - RESEARCH Kei Sonoda, MD
Proteinuria in Mid-Life and 39-Year All-Cause Mortality; The Honolulu Heart Program.
Kei Sonoda, MD; Gotaro Kojima, MD; Suryadutt Venkat, MD, MPH; Christina Bell, MD; Randi Chen, MS;
Helen Petrovitch, MD; Robert D. Abbott, PhD; G. Webster Ross, MD; J. David Curb, MD, MPH; Kamal
Masaki, MD. Department of Internal Medici
Introduction: Previous evidence has shown that proteinuria is an independent risk factor for increased
all-cause mortality, cardiovascular disease, and stroke. However, there have been no long-term
population based studies of proteinuria and mortality over 3 decades.
Methods: Established in 1965, the Honolulu Heart Program is a longitudinal cohort study of 8,006
Japanese-American men from the island of Oahu, Hawaii, born 1900-1919. Proteinuria was measured at
mid-life using urine dipsticks during exam 1 (1965-68, n=8,006) and exam 3 (1971-74, n=6860).
Participants were classified as ‘no proteinuria’ if they tested negative at both exams, ‘transient
proteinuria’ if they tested positive at one of the exams, and ‘persistent proteinuria’ if they tested
positive at both exams. Follow-up began at the end of exam 3, and data on all-cause mortality were
available through December 2010, for up to 39 years of follow-up. This study was approved by IRB of
Kuakini Medical Center.
Results: Prevalence rates were 6.4% and 1.3% for transient and persistent proteinuria respectively, and
increased significantly with age groups (p

ILLINOIS PODIUM PRESENTATION - RESEARCH Rojina Pant, MBBS
Application of Myocardial Perfusion Imaging in a Chest-Pain Rule Out Cohort
Rojina Pant, MBBS, Jeffrey Cook MD, Mukesh Gopalakrishnan MD, Kiran Regmi MD, Carlos Urdininea
MD, Toyiba Syed MD, German Rossell MD, Dana Villines, Lloyd Klein MD.
Introduction: Majority of acute coronary syndrome “rule out” admissions are discharged the next day
after a negative stress test. We sought to identify these low-risk patients who underwent Myocardial
Perfusion Imaging (MPI), and analyze their course from the perspective of test propriety.
Methods: A one year cohort of 265 patients admitted with chest pain who underwent MPI was studied
retrospectively. Patients with prior history of coronary artery disease (CAD) were excluded. Pretest
probability was calculated using the Diamond and Forrester Score (DFS). The pretest probability at which
a negative test would reduce the post-test probability to

MICHIGAN PODIUM PRESENTATION - RESEARCH Tezo Anto Karedan, MD
Racial differences in Men with Breast Cancer
Siva Talluri, MD *; Tezo Karedan, MD *; Radhika Kakarala, MD ,MS *; Madhuri Kakarala, MD, MS, PhD**,
* Department of Internal medicine, McLaren Regional medical center, Flint, MI ;**Department of
Internal medicine, University of Michigan, Ann Arbor, MI.
Introduction: Breast cancer in men is rare and constitutes less than 1% of all cancers in males. The
objective of our study is to compare the presenting characteristics, and survival rates in Caucasian and
African-American men with breast cancer.
Methods: We analyzed a retrospective cohort of breast cancer patients included in National Cancer
Institute’s Surveillance, Epidemiology, and End Results (SEER) Registry from 1990 to 2007. Seventeen
registries are enrolled in the SEER database and include approximately 26% of the US population.
Racial differences in demographic and tumor characteristics at the time of diagnosis were compared
using chi-square test. Breast cancer and racial specific survival was compared using Kaplan-Meier
method. Cox proportional hazards regression model was used to determine the independent effect of
race on survival after adjusting for age of patient, stage, grade and receptor status of tumor.
Results: We included 2348 men with breast cancer in our study; they were Caucasians (2075), and
African-American (273).
A greater proportion of African American men presenting with breast cancer were younger than 60
years old as compared to Caucasians (46% vs. 31%) p< 0.001. They also more often presented with
advanced disease (12% vs. 6%), higher grade lesions (34% vs. 29%), tumor size greater than 2 cm (48%
vs. 37%) and lymph node involvement (35% vs. 32%) compared to Caucasians. Tumors were more likely
to be progesterone receptor negative (21% vs. 11%) and estrogen receptor negative (8% vs. 4%). All
differences were statistically significant (p

MINNESOTA PODIUM PRESENTATION - RESEARCH Melissa A Wells, MD
Sex differences in cytokine response of patients with rheumatoid arthritis.
Melissa A Wells, MD John M Davis III MD, Keith L Knutson PhD, Michael A Strausbauch, Cynthia S
Crowson, Terry M Therneau, Eric L Matteson MD, Sherine E Gabriel MD
Introduction: Sex differences have been observed in the incidences of autoimmune disorders as well as
in the cytokine response to immune stimulation. However, very little is understood regarding sex
differences in cytokine response in the setting of autoimmune disorders. We sought to explore the sex
differences in cytokine response in patients with rheumatoid arthritis (RA).
Methods: We performed a cross-sectional analysis of data from a population-based cohort study of
patients with RA. Patient information collected included age, RA duration, BMI, CRP, HAQ disability
index, current smoking status, rheumatoid factor positivity, anti-CCP antibody positivity, and RA
medication use. Peripheral blood mononuclear cells (PBMC) from subjects were stimulated with a
variety of stimulants to determine their cytokine response. Stimulants included anti-CD3/anti-CD28, CpG
oligonucleotides (CpG), combined cytomegalovirus and Epstein Barr virus lysates (CMV/EBV), phorbol
myristate acetate with ionomycin (PMA/ionomycin), phytohemagglutinin, and combined Staphylococcal
enterotoxins A and B (SEA/SEB). Collected supernatants were analyzed for 17 cytokines using
multiplexed immunoassays. The data were normalized using mixed models with random effects for
subject and plate, to adjust for assay effects. Males and females were compared using linear regression
models on the ranks of the cytokine values (due to skewed distributions) with adjustment for the patient
factors listed above.
Results: Our study included 234 females (mean age 59.6 years) and 83 males (mean age 63.3
years). Significant differences (p-value

NEVADA PODIUM PRESENTATION - RESEARCH Ramesh Keerthi Gadam, MBBS
Can It Wait Until The Morning? - A Retrospective Study of the Clinical Utility of Blood Culture Gram
Stain Reports Provided Between 10:00 PM and 6:00 AA
Ramesh Keerthi Gadam, MBBS (Resident Internal Medicine, UNSOM-Las Vegas),Additional Authors:
Fuzhan Parhizgar M.D (Resident Internal Medicine, UNSOM-Las Vegas), Kimberly D.Leuthner Pharm D
(UMC), Brandi Miller Pharm D candidate (UMC), Jar
Introduction: Automated blood culture systems detect bacterial growth at any time. Lab policy requires
technicians to report results of a Gram stain to the patients’ physician immediately, resulting in phone
calls often between 10 PM-6AM. Non-hospital based physicians have asked that these calls be delayed
until the next morning, arguing that initial empiric antibiotic therapy is often appropriate and is rarely
modified based upon gram stain findings. Hypothesis: Antibiotic therapy started prior to the availability
of Gram stain results provides adequate coverage of organisms subsequently isolated in > 95% of cases.
Methods: This is a retrospective study using 40 consecutive blood culture isolates from bacteremic
events from the month of September 2011 that first became positive after 10 PM and before 6 AM in
patients hospitalized at UMC. Gram stain characteristics and culture sensitivity results were recorded.
The antibiotics these patients were receiving during the day of or day before the blood culture first was
first positive were recorded. Algorithms were devised to determine if antibiotic therapy would have
been modified based upon patient history, present therapy and Gram stain results. Hypothesis will be
rejected if < 95% of cases are on appropriate antibiotic therapy prior to gram stain results.
Results: 1. At the time of Gram stain results, 16 out of 40 patients had inadequate antibiotic coverage
based upon pre-determined algorithms (4 yeast, 4 gram negative bacilli, others gram positive cocci in
clusters.) i.e. the hypothesis was rejected. 2. Of the 16 patients with inadequate coverage at the time of
Gram stain, 3 had health care associated problems, one was a lateral transfer from another hospital, one
was a transfer from a rehab facility, and one was immunodeficient. 3. When followed through to the
culture sensitivity 22 had inadequate antibiotic coverage at the time of gram stain results. 4. The
modifications suggested by Gram stain based on the algorithm would have corrected the coverage in 13
out of the 16 patients. And would have reduced the total number of inadequate coverage based on
culture sensitivity to 9 from 22.
Conclusion: Gram stain reporting during off hours should be continued. Special emphasis should be
placed on the patients who are immune-deficient, chronic illnesses requiring hospital care, and transfers
from other health care facilities.
29

NEW HAMPSHIRE PODIUM PRESENTATION - RESEARCH David Nagel, MD
Nuclear PDE1 Induces Vascular Remodeling and Atherosclerosis
David Nagel MD, PhD Toru Aizawa MD, Bradford C. Berk MD, PhD, and Chen Yan PhD
Introduction: According to the CDC, in 2006, 631,636 people died of heart disease, and in 2010, it was
estimated that heart disease would cost the United States $316.4 billion. Abnormal vascular smooth
muscle cell (VSMC) growth has been implicated in a multitude of cardiovascular diseases, including
stroke, atherosclerosis, and restenosis. Numerous studies have shown that cyclic nucleotides, cAMP and
cGMP, inhibit VSMC proliferation. Phosphodiesterases (PDEs), through inactivation of cyclic nucleotides,
play critical roles in controlling intracellular signal transduction. PDE1 is a Ca 2+ /Calmodulin-stimulated
PDE, which hydrolyzes both cAMP and cGMP, but has a higher affinity for cGMP. Because cGMP is a key
mediator of VSMC growth, we hypothesized that a nuclear isozyme of PDE1 may downregulate cGMP
and promote VSMC growth.
Methods: We utilized rat balloon-injured carotid arteries, murine ligated carotid arteries, and human
coronary arteries (post-mortem), to perform immunohistochemical anaylsis. Morphometric and cell
counting analyses were performed with Image Pro 6.0 software. Rat aortic smooth muscle cells (RASM)
were prepared using enzymatic digestion of aortas from rats (Sprague-Dawley), and cells were grown in
medium (DMEM) containing 10% fetal bovine serum in a humidified incubator. Fibrillar collagen gels
were made by diluting rat type 1 collagen (PureCol, Inamed) in freshly prepared 7x DMEM
(Cellgro). Monomeric collagen-coated dishes were prepared by diluting the collagen in water and acetic
acid (0.5 N). To prevent collagen denaturation, every step of the protocol was performed on ice.
Results: We demonstrated that PDE1 localized to the cytoplasm in quiescent VSMC located in the
medial layer, yet PDE1 was primarily located in the nuclei of neointimal VSMC. In addition, by
manipulating the collagen substrate of culture dishes, we found that the subcellular location of PDE1 is
dependent upon the phenotypic state of the VSMC. We demonstrated that VSMC growth was
significantly reduced both in the presence of a pharmacological inhibitor (IC86340) and a siRNA that
selectively target PDE1 expression. These phenomena were corroborated with in vivo experiments
whereby neointimal formation was reduced with local administration of a PDE1 inhibitor. Finally, similar
experiments were performed with ex-vivo human saphenous vein grafts that were cultured and treated
with PDE1 inhibitors.
Conclusion: These results suggest that nuclear PDE1 may play an important role in regulating VSMC
growth by modulating specific subcellular pools of cGMP. Therefore, inhibitors that specifically block the
function of nuclear PDE1 may prove to be a novel therapy to maintain VSMC differentiation and
attenuate atherosclerosis development.
30

NEW YORK PODIUM PRESENTATION - RESEARCH Dany A Raad, MD
Are We Increasing the Risk of Stroke by Adding Proton Pump Inhibitors to Clopidogrel? A Systematic
Review and Meta-Analysis
Dany A Raad, MD Co-authors: Keenan Adib, MD, Rabi Yacoub, MD, Lynn Chouhfeh, MD, Eiad Nasser, MD
Introduction: Around 795,000 patients suffer a stroke every year in the US with an estimated direct and
indirect cost of 73.7 billion dollars in 2010. Clopidogrel has become a cornerstone in secondary
prevention of cardiovascular and cerebrovascular diseases. Many clinicians prescribe proton pump
inhibitors (PPI) with clopidogrel to reduce the risk of gastrointestinal bleeding. Recent evidence suggests
that PPI attenuate the antiplatelet effects of clopidogrel. Most studies that analyzed the effect of
concomitant use of PPI and clopidogrel focused on cardiovascular outcomes and mortality. Only few
studies have analyzed the effects of this concomitant use on cerebrovascular outcomes, and were
mostly observational and limited in numbers. The objective of this study was to systematically review
the effect of adding PPI to clopidogrel on the risk of ischemic stroke.
Methods: We searched in October 2011 the following electronic databases starting with their dates of
inception: MEDLINE, EMBASE, Web of Science, and Healthstar, in addition to abstracts of pertinent
scientific meetings (ACC, AHA, DDW, ACG, AAN and ISC; 2006-2011). Two investigators screened title
and abstracts then full text in duplicate and independently. We included both observational and
randomized controlled trials (RCT) in the search. The primary outcome was occurrence of ischemic
stroke. We analyzed data using Stata and Review Manager. We used odds ratio (OR) to evaluate the risk
and I 2 test to evaluate study heterogeneity. The results were presented using forest plot. Analysis was
performed using random effects estimate. Publication bias was calculated using Egger’s test.
Results: We reviewed 1803 publications and found 14 relevant studies that included stroke as an
outcome: 3 had insufficient data; 9 were published as full texts and 2 as abstracts. All studies were
observational and no RCT was found. A total of 119,925 patients were included of which 32,716 were on
clopidogrel + PPI and 87,209 were on clopidogrel alone. The addition of PPI to clopidogrel significantly
increased the risk of ischemic stroke (OR = 1.39, 95% CI = 1.17 – 1.65, p < 0.001), heterogeneity was
found across the studies (I 2 = 52%, p = 0.02), and no publication bias was found (Bias Coefficient = -0.95,
95% CI = -3.94 to 2.05, p = 0.47).
Conclusion: This meta-analysis found that adding PPI to clopidogrel increases the risk of ischemic stroke.
To our knowledge, this is the first meta-analysis studying the concomitant use of PPI and clopidogrel and
its effect on ischemic stroke. Well powered randomized clinical trials are warranted to confirm this
finding.
31

OHIO PODIUM PRESENTATION - RESEARCH Georges Nakhoul, MD
Routine Backup Testing for Negative Rapid Antigen Detection Testing (RADT) in the Management of
Acute Pharyngitis in Adults has Little Value and is Expensive
Georges Nakhoul, MD All Authors: Georges Nakhoul MD, John Hickner MD, MSc
Introduction: The diagnosis of Group A beta-hemolytic streptococcal pharyngitis is based on a
combination of clinical scores such as the Centor criteria and point of care rapid antigen detection tests
(RADT). In adults, a confirmatory culture of a negative RADT is not mandatory but it is widely done in
clinical practice. Our hypothesis is that the routine backup testing for negative RADT adds costs with
minimal clinical benefit.
Methods: Using the electronic medical record database, we performed an audit of patients over 18
years old presenting to Cleveland Clinic primary care offices in 2009 & 2010 that had a primary diagnosis
of acute pharyngitis (ICD codes 462, 034.0). We determined the number of patients that had a negative
RADT (Acceava is the RADT used at the Cleveland Clinic) and a positive confirmatory test (DNA probe for
group A beta hemolytic strep, which is equivalent to culture). We calculated the specificity and negative
predictive value of the RADT using DNA probe as the gold standard. We also determined whether a
subsequently positive DNA probe lead to a change in therapy.
Results: From a total of 25,130 patients with pharyngitis, 4,708 had no testing (18.7%) and 20,422
(81.3%) were tested by RADT alone (3520 patients), DNA probe alone (832 patients) or both (16071
patients). Of the 15,554 patients that had a negative RADT and follow up DNA probe, 93.9% had a
negative DNA probe yielding a RADT specificity of 97.3% and a negative predictive value of 93.9%. Of the
953 patients who had a negative RADT and a positive DNA probe, 19.6% were prescribed an antibiotic
before the DNA probe test results were available, and 33.8% received an antibiotic prescription in the
week following the initial office visit. 46.6% were not prescribed an antibiotic even after the DNA probe
test returned positive. Of the 15,554 patients that had a negative RADT, management was altered in
only 2.1% patients, at a total cost of $1,602,062, or $4,975 per change in patient therapy.
Conclusion: The RADT we use at Cleveland Clinic (Acceava) has an excellent specificity and negative
predictive value. As used by Cleveland Clinic physicians, routine back-up testing lead to change of
management in only 2.1% of the patients at a total cost of $1,602,062. Using a chart audit we will
evaluate the potential negative consequences for the 444 patients with a negative RADT but positive
DNA probe who were not treated with an antibiotic.
32

PENNSYLVANIA PODIUM PRESENTATION - RESEARCH Julian Nahuel Diaz
Fraga, MD
Early Intravenous (IV) To Oral (PO) Azithromycin Conversion in Hospitalized Patients with Community
Acquired Pneumonia (CAP).
Julian Nahuel Diaz Fraga, MDArchana Satyal-Chaudhary, MD Andrew Crocker, MD Shuchi Gulati, MD
Gaurav Gulati, MD Anup Subedee, MD David George, MD.
Introduction: Many patients admitted with community-acquired pneumonia (CAP) continue to receive
IV antibiotics for longer than necessary. Early conversion from IV to PO route has been reported to
increase patient safety and comfort, reduce cost, and facilitate earlier discharge, without compromising
medical care. We developed an intervention strategy to decrease the time from IV to PO conversion of
azithromycin therapy for CAP in hospitalized patients by 20% over a 3 month period.
Methods: This resident-led quality improvement project was conducted in a 750-bed community
teaching hospital in which all medications are ordered online. We created a radio button option added
to electronic CAP order set to allow physicians to preauthorize pharmacists to convert IV to PO
azithromycin for patients meeting certain criteria. Hospitalist and resident staff received real time
feedback to reinforce education and address variation in practice patterns. Pharmacy developed a
system of rapid identification of candidates for antibiotic conversion. Pre- and post-intervention
measures included time to conversion from IV to PO antibiotic dosing, length of stay, rates of
readmission, death, transfer to a higher level of care, and reconversion to IV antibiotic therapy. Baseline
and final statistics were collected via electronic health record (EHR) chart review.
Results: The average time from IV to PO azithromycin conversion was decreased by more than 50% (1 ½
days) after our intervention. A direct cost savings was estimated to be $17,500 per year and nursing
time reduced by 19.4 days /year (estimate extra 10 minutes per IV administration.) There was no
statistically significant difference in the length of stay, rates of readmission, death, transfer to a higher
level of care, and reconversion to IV antibiotic therapy. Physician acceptance was excellent, and the
process has been extended to the COPD order set.
Conclusion: A simple change in process substantially reduces time from IV to PO azithromycin
conversion in hospitalized patients with CAP, without compromising medical care. The process reduces
cost and saves nursing time. In order to impact length of stay, the team will develop the current
program to standardize discharge criteria and define appropriate oral antibiotic choice in this era of
increased pneumococcal resistance to azithromycin.
33

PENNSYLVANIA PODIUM PRESENTATION - RESEARCH Nimesh K Patel, MD
Serum Bilirubin as a Prognostic Marker in Patients with Acute Decompensated Heart Failure
Nimesh K Patel, MD J Chintanaboina MD, M Haner PhD, A Sethi MD, W Tanyous MD, A Lalos MD, S
Pancholy MD
Introduction: Congestive hepatopathy leading to abnormal liver function tests (LFTs) is a common
finding in patients with acute decompensated heart failure (HF). The aim of this study was to determine
the prognostic significance, if any, of abnormal LFTs in acute decompensated heart failure, as this has
not been extensively studied so far.
Methods: A retrospective chart review of all adult patients (> 18years of age) who were admitted to a
community hospital with a diagnosis of acute decompensated HF during the period from Jan 1, 2008 to
June 30, 2010 was performed. Of the 187 patients identified, 170 patients were included in the study.
Exclusion criteria included insufficient laboratory data, acute/chronic kidney injury (serum creatinine >
2mg/dl), acute myocardial infarction, hepatitis (drug-induced/infectious), malignancy and death from
any cause other than HF. Primary end points of the study were readmission or death secondary to
HF. The Cox proportional hazard model was used for statistical analysis of the data. p values = 0.05 were
considered statistically significant.
Results: The mean age of the patients was 78.5 years. Of the 170 patients, 42% were male and 122 were
readmitted secondary to HF during the study period. Serum total bilirubin (p 1.3 mg/dl on admission or an EF < 35% collectively
had a readmission rate that was 87% ± 20% (p< 0.05) higher than those without these criteria.
Conclusion: In patients with acute decompensated HF, elevated serum total bilirubin on admission with
or without low EF (

ASSOCIATE RESEARCH POSTER FINALISTS
35

ARIZONA POSTER FINALIST - RESEARCH Nduka-Obi F Ossai, MBBS
Border-Crossers' Nephropathy: The Risk of Coming to America
Nduka-obi Ossai, MD, Harold M. Szerlip, MD.
Introduction: The 380 mile border between Mexico and Arizona has become a prime entry point for
persons wanting to enter the United States. Because of increased enforcement, these individuals usually
attempt to cross the border in desolate areas where they may wander for days without food or water
before being "rescued". The summer of 2010 was one of the five hottest summers on record. During
2010, 232 individuals died trying to cross the border into Arizona and 212,202 people were
apprehended in the Tucson Sector. The University of Arizona Medical Center, South Campus is one of
the closest tertiary care medical centers to the Mexican border. Detainees with medical problems are
frequently brouqht to this campus. Herein we describe our experience with Myoglobinuric acute kidney
injury (AKI) in these border-crossers.
Methods: We reviewed the records of all border crossers admitted between June 1, 2010 - June 30,
2011 with AKI as defined by AKIN criteria who also had an elevation of CPK > 1000 IU/L. We recorded
the age, gender, temperature, days in the desert, serum creatinine on presentation, CPK on
presentation, days in the desert, need for dialysis, length of hospital stay and serum creatinine on
discharge.
Results: During this time period 42 people were diagnosed with Myolobinuric AKI. On presentation all
patients were vigorously resuscitated with either 0.9% NaCI or a mixture of NaCI and NaHC03. The mean
age was 32.5 years (range 18-53). 38 were male and 4 female. They had wandered in the desert
between 1 and 10 days with a mean of 4.2 days. Seven had stage 1 AKI, 10 stage 2 and 25 stage 3. Five
patients required dialysis. Only 1 patient had a temperature> 100.6F on arrival. CPKs ranged between
1101 and 447,966 IU/L. Length of stay was between 1 and 17 days with a mean of 4.0 days. Two patients
were discharged on hemodialysis and 8 were discharged with serum creatinine >1.3 mg/dl.
Conclusion: This is the largest series of Myoglobinuric AKI reported in border-crossers. The presumed
etiology is excessive heat combined with volume depletion and stressful exercise. We have coined the
term "border-crossers nephropathy" for this disorder. Many of these patients may develop CKD and
require nephrology care in their home country.
36

ARKANSAS POSTER FINALIST - RESEARCH Sadip Pant, MBBS
Does the Increase in Mortality in Patients with Acute Myocardial Infarction Admitted on Weekends
Still Exist? - A Nationwide Analysis
Sadip Pant, MBBS Second Author: Abhishek Deshmukh, MD (Cardiology) Third Author: Jawahar L Mehta,
MD, PhD (Cardiology)
Introduction: Previous studies have suggested worse outcomes for patients admitted with acute
myocardial infarction (AMI) on weekends. Only limited availability of resources on weekends has been
thought of as the major causative factor. In general, improvements in system based practices and push
to reduce the door to balloon time has contributed towards better outcomes of AMI. Nonetheless, there
are no data on trends in outcomes of AMI patients hospitalized on weekends in recent years.
Methods: This was a cross sectional study using the Nationwide Inpatient Sample from the years 2000
to 2008. A total of 5,848,502 discharges with AMI and its related revascularization procedures were
identified through appropriate ICD 9 codes (410.x or 411.1). Weekend admissions were defined as all
admissions between midnight Friday through midnight Sunday. The primary outcome measured was inhospital
mortality.
Results: Of the 5,848,502 patients with the diagnosis AMI, 25.3% were admitted on a weekend. Overall,
patients admitted on a weekend had significantly increased mortality (6.66% vs. 6.13%, p

CANADA POSTER FINALIST - RESEARCH George Ou, MD
Hyponatremia in the Orthopedic Patient
George Ou, MD, Eileen Hennrikus, MD, FACP, Bradley Kinney, BS, Erik Lehman, MS, Abdulla Damluji, MD,
MPH
Introduction: Death in patients hospitalized for musculoskeletal surgery is higher in those with
hyponatremia than those without. If we can identify the cause of hyponatremia, we can reduce
mortality.
Methods: A one year, retrospective chart review of all adult, age > 18, hospitalized orthopedic surgical
patients was performed. Sodium (Na) levels were documented pre and post operatively. Hyponatremia
was defined as Na

CALIFORNIA POSTER FINALIST - RESEARCH Vincent Kao, DO
Role of Protein Kinase C in Acetominophen-Induced Liver Injury
Vincent Kao, DO MS, Behnam Saberi, MD, Maria D Ybanez, William Gaarde, Derick Han, PharmD, Neil
Kaplowitz, MD
Introduction: Acetaminophen (APAP) is the most common cause of drug induced liver injury (DILI).
Traditionally, hepatotoxicity of APAP had been believed to the result of cellular injury caused by NAPQI,
a reactive metabolite of APAP formed by the actions of cytochrome P450. However, recent studies from
our lab have shown that activation of signal transduction pathways including JNK is required for APAPinduced
liver injury to occur. We had previously shown that inhibition of protein kinase C (PKC) protects
against hydrogen peroxide (H2O2) induced necrosis in primary culture hepatocyte (AJP 2008
Jul;295(1):C50-63). In this work we investigated the possible role of PKC in APAP-induced liver injury.
Methods: Hepatocytes were isolated from C57 BL/6 mice and plated on 60mm culture dishes. After the
culture medium was changed to serum free medium, the hepatocytes were then treated with various
inhibitors, such as PKC inhibitors. After 16 h of various treatments, cells were double stained with
Hoechst 33258 and Sytox green. Culture dishes were then observed under an OLYMPUS fluorescent
microscope. Quantitation of total and apoptotic cells was performed and necrotic cells (Sytox green
positive) were determined by counting the same field. Aliquots from cytoplasm or membrane
extracts were fractionated on SDS-PAGE gel (Bio-Rad), and proteins were transferred to membranes
and visualized by immunoblot analysis using antisera for PKC-a (obtained from Cell Signaling
Technologies, Danvers, MD). Antisense oligonucleotides (ASO) targeting mouse PKC-a and a chemical
control oligonucleotide (Isis Pharmaceuticals, Carlsbad, CA) were synthesized as 20-nt uniform
phosphorothioate chimeric oligonucleotides that support RNase H-based cleavage of the targeted
mRNA. To knockdown PKC-a, mice were injected intraperitoneally with ASO seven times (50 mg/Kg
every other day).
Results: The treatment of APAP to mice appears to primarily activate PKC-a in the liver. The activation of
PKC-a occurs early (within 1 hour) with a time course very similar to JNK activation in the liver. PKC
activation appears to mediate APAP hepatotoxicity both in cultured primary hepatocytes and in vivo.
Pre-treatment of primary cultured hepatocytes with PKC inhibitors (Ro-31-8425 or Go6983) significantly
decreased necrosis caused by APAP (~52% and 29% respectively). Similarly, pretreatment with PKC
inhibitor (Ro-31-8425) to mice significantly protected against APAP-induced liver injury. The importance
of PKC-a mediating APAP-induced liver injury was confirmed using antisense oligonucleotide (ASO).
Silencing PKC-a using ASO significantly protected against APAP-induced liver injury in mice. We are
presently investigating the interplay between PKC-a and JNK in mediating APAP-induced liver injury.
Conclusion: Our data suggests that PKC-a activation plays an important role in APAP induced liver injury.
The inhibition of PKC-a may represent a new therapeutic target to prevent APAP hepatotoxicity and
possibly other drugs that cause DILI.
39

CALIFORNIA POSTER FINALIST - RESEARCH Theresa L Nilson, MD
Bacterial Infections in Patients with End Stage Renal Disease
Theresa L. Nilson, M.D. (Associate) Yuichi Masuda, M.D., Ph.D. Hirohito Ichii, M.D. Nosratola D. Vaziri,
M.D.
Introduction: Bacterial infections are the second most common cause of death in patients with end
stage renal disease (ESRD). This is largely due to uremia-induced immune the deficiency which is caused
by dendritic cell depletion and dysfunction, T and B lymphocyte abnormalities and impaired phagocytic
of polymorphonuclear leukocyte (PMNs). Intravenous (IV) iron preparations are commonly used in the
management of anemia in ESRD patients. Recently the use of IV iron preparations in ESRD patients has
dramatically increased in order to lower the requirement for erythropoiesis stimulating agents (ESA). In
many instances IV iron preparations are administered on a routine basis with insufficient attention to
the total body iron stores. Iron overload is associated with increased incidence of bacterial infections in
patients with and without ESRD and IV administration of iron sucrose in ESRD patients has been shown
to impair phagocytic and bacteriocidal capacity of PMNs against E. Coli. IV iron preparations consist of a
core of elemental iron covered by a carbohydrate shell. In addition to the elemental iron, the
carbohydrate shell of these compounds may potentially affect PMNs and monocytes. The present study
was designed to examine the effect of one of the commonly used IV iron preparations, iron sucrose, on
the phagocytic capacity of PMNs from a group of normal individuals against Gram positive
(Staphylococcus aureus) and Gram negative (Escherichia coli). To this end iron sucrose was added to
heparinized blood samples from each subject at pharmacologically-relevant concentrations and
incubated for 4 hr and 24 hr at 37º C to simulate in vivo condition. Blood samples mixed with equal
volume of saline solution served as controls. To isolate the possible effect of the complex carbohydrate
shell from that of the elemental iron core of the drug, blood samples were simultaneously treated with
iron sucrose and the iron chelator, desferrioxamine. The study showed that iron sucrose causes a
significant concentration- and time-dependent suppression of phagocytic activities of PMNs against
both Gram positive and Gram negative bacteria. Iron sucrose induced suppression of PMN phagocytic
activity was prevented by the iron chelator, desferrioxamine, thus precluding the contribution of the
carbohydrate shell of iron sucrose to the PMN dysfunction. Thus, at pharmacologically-relevant
concentrations iron sucrose significantly inhibits phagocytic activities of PMNs against both Gram
positive and Gram negative bacteria. The deleterious effect of iron sucrose was mediated by its
elemental iron core but not to its carbohydrate shell and as such may be shared by other IV iron
preparation.
40

CALIFORNIA POSTER FINALIST - RESEARCH Patrick S Lin, MD PhD
The Role of the Retinoblastoma/E2F1 Tumor Suppressor Pathway in the Lesion Recognition Step of
Nucleotide Excision Repair
Patrick S. Lin, Lisa McPherson, Aubrey Chen, Julien Sage, James Ford
Introduction: The retinoblastoma Rb/E2F tumor suppressor pathway plays a major role in cell cycle
regulation. The pRb protein, along with p107 and p130, exerts its anti-proliferative effects by binding to
the E2F family of transcription factors known to regulate essential genes throughout the cell
cycle. Given that cell cycle and DNA repair are intimately linked, we sought to investigate the role of the
Rb/E2F1 pathway in nucleotide excision repair (NER) in mouse embryonic fibroblasts (MEFs).
Methods: Rb-/- and Rb-/-;p107-/-;p130-/- MEFs were used in our study. Repair of cyclobutane
pyrimidine dimers (CPDs) and 6-4 pyrimidine-pyrimidone photoproducts (6-4PPs) at different times
following UV-C (254nm) irradiation was measured using ELISA. Real time RT-PCR was used to evaluate
specific NER transcripts. Putative E2F1 binding sites were determined using a rigorous algorithm
(http://compel.bionet.nsc.ru/FunSite/SiteScan.html). Chromatin immunoprecipitation assays were
performed to establish E2F1 binding to putative promoters.
Results: Rb-/-;p107-/-;p130-/- MEFs repaired both CPDs and 6-4PPs at higher efficiency than did
wildtype cells following UV-C irradiation. The expression of damaged DNA binding gene DDB2 involved
in the DNA lesion recognition step was elevated in the Rb family-deficient MEFs. Conversely, E2F1-/-
MEFs were impaired for the removal of both CPDs and 6-4PPs. Furthermore, wildtype cells induced a
higher expression of DDB2 and xeroderma pigmentosum gene XPC transcript levels than did E2F1-/-
cells. ChIP assays confirmed the binding of E2F1 to a novel XPC promoter in a UV-dependent manner,
suggesting that E2F1 is a transcriptional regulator of XPC.
Conclusion: The discovery of a regulatory function of E2F1 in the NER pathway demonstrates a novel
role for E2F1 in DNA repair in addition to its well-established functions in cell cycle checkpoint, cell cycle
progression, and apoptosis. Specifically, our study demonstrates that E2F1 is involved in the regulation
of DNA lesion recognition factors DDB2 and XPC in mouse NER, suggesting a role of E2F1 not only as a
responder of DNA damage but also as an effector of DNA repair. Most importantly, a thorough
understanding of the mechanism by which the Rb/E2F1 tumor suppressor pathway regulates NER will
provide valuable insights into potential targets for therapeutic intervention in the treatment against
cancer.
41

CALIFORNIA POSTER FINALIST - RESEARCH Benton T Ashlock, MD
Employment of a Standardized Management Strategy for Asymptomatic Distal Deep Venous
Thrombosis in the ICU.
Benton Ashlock, MD and Kenneth Serio, MD
Introduction: With the increased use of Doppler ultrasound to screen for deep venous thombosis (DVT),
the incidence of asymptomatic or incidental below-knee (distal) DVT is increasing in the ICU. Currently,
there is a paucity of evidence to guide appropriate management once distal DVT is discovered. Eightyeight
percent of distal DVT in our institution are diagnosed in the ICU. Employing a standardized
management strategy in the ICU, we sought to determine the natural history of distal DVT, determine
the rate of progression from distal to proximal DVT, determine if the presence of distal DVT alters
physician behavior (with regard to DVT prophylaxis), and to determine risk factors to help predict which
patients will undergo progression from distal to proximal DVT in this clinical setting.
Methods: A single institution prospective observational trial was conducted. Patients admitted to the
ICU at Scripps Clinic Green Hospital between 10/2008-10/2010 were studies utilizing a uniform DVT
management strategy. All medical ICU patients (with clinical indications) were screened for DVT with
lower extremity Doppler ultrasound studies within 24 hrs of ICU admission and every 7 days. Patients
with progression to proximal DVT or pulmonary embolism (PE) were identified and treated per the usual
standard of care. Seventy-seven patients with isolated asymptomatic calf DVT were enrolled and
underwent repeat lower extremity Doppler evaluation every 48 hours for a total of 12 days. Patients
were subsequently followed for a total of 30 days via the institution’s electronic medical record to
monitor for diagnosis of subsequent proximal DVT or PE.
Results: Among the 77 subjects, 58% completed the 6 subsequent Doppler evaluations. Fifty percent of
distal DVT were diagnosed on the initial screen while the remaining 50% were identified 24 hrs or later
after ICU admission. Ten of 77 (13.0%) experienced progression to proximal DVT, and one was found
incidentally to have PE. Mean/median latency to progression was 10.8/8.0 days. In 27.3% of the distal
DVT diagnosed cases, the physician increased the extent of either pharmacologic or mecanical DVT
prophylaxis in response to the positive study result. Risk factors including time of diagnosis, femoral
central catheter presence, history of cancer, race, and primary diagnosis were not predictive of the rate
of progression. The only risk factors that reached significance were the history of DVT/PE and female
sex. 30-day mortality was nearly double in patients who progressed, 25% vs. 13%.
Conclusion: Distal DVT’s constitute some risk for thomboembolic disease; however most of our patients
did not progress to proximal DVT despite the decreased mobility of hospitalization and ICU care. Risk
factors commonly assumed to be associated with thromboembolic disease we largely equal in both
groups. The incidental diagnosis of pulmonary embolism demonstrated the heterogeneity of treatment
between hospitals and the need for clear guidelines with in the management of distal DVT. Prophylaxis
was increased in response to diagnosis of distal DVT which likely demonstrates appropriate prophylaxis
was being unnecessarily avoided. The complete lack of clinically significant thromboembolic disease
reiterates the appropriateness of the retracted recommendation to monitor distal DVT’s with serial
doppler ultrasound to avoid unnecessary anticoagulation as well as to catch and treat patients who do
progress from distal to proximal DVT.
42

CALIFORNIA POSTER FINALIST - RESEARCH Lueng Tcheung, MD
Variations in the Linkage of Care of Newly Diagnosed Human Immunodeficiency Virus (HIV) at a
Veterans Administration (VA) Hospital
Lueng Tcheung, Matthew Goetz
Introduction: In the VA Healthcare System, patients have access to healthcare that is not limited by lack
of income. Nonetheless, variations in care may persist. In response to VA initiatives to increase testing
for HIV, we have sought to assess factors associated with variations in receipt of care in persons newly
found to be HIV infected.
Methods: We reviewed electronic medical records of 170 patients newly diagnosed as HIV-infected
from October 1998 through March 2011 at the Greater Los Angeles Veterans Administration Healthcare
System. The principle outcome measures were the time from testing positive to result notification, first
infectious disease (ID) clinic appointment and to initiation of antiretroviral therapy (ART). Covariates of
interest included age, race, housing status and whether testing was done after July 2005 when a new
initiative to promote HIV testing was implemented.
Results: For 165 patients the median quartile time from positive test to result notification was 11 days; 5
had no further follow-up in the WLAVA system. Of these 165 patients, 134 (81%) had an ID appointment
within three months of a reactive HIV test. Within three months from the date that the patient had their
CD4 cell count checked, ART was started in 58/69 (84%), 16/27 (59%), and 18/67 (27%) of patients with
=351 CD4+ cells/L, respectively. 73/92 (79%) patients achieved virological
suppression (

CALIFORNIA POSTER FINALIST - RESEARCH Susan Wong, MD
Outcomes of Older Patients who Initiate Chronic Dialysis in the Inpatient Setting.
Susan Wong, MD William Kreuter, MPA Ann M. O’Hare, MD MA
Introduction: Older adults represent the fastest growing contingent of the population starting chronic
dialysis for end-stage renal disease (ESRD). Initiating chronic dialysis during hospitalization for acute
illness is unfavorable but common in older adults, and their prognosis is largely unknown.
Methods: We used data from a national registry on ESRD to conduct a retrospective study on 585,291
Medicare beneficiaries age =67 years who initiated chronic dialysis between 1/1/1995 to 12/31/2008.
We examined mortality and its association with inpatient initiation of chronic dialysis and intensity of
care received during the index hospitalization, including duration of hospital stay, intensive care unit
(ICU) admission and receipt of an intensive procedure (mechanical ventilation, cardiopulmonary
resuscitation and feeding tube placement).
Results: Overall, 53.9% of patients initiated chronic dialysis as an inpatient. Of these patients, 45.8%
were admitted to the ICU and 7.4% had received at least one intensive procedure. Average length of
stay during the index hospitalization was 14.8 days (median 11 days). Mean survival was 1.8 years (1.1
median) in patients who initiated dialysis as an inpatient as compared with 2.2 years (median 1.5 years)
in those who initiated dialysis as an outpatient (p84 years (61.4% v. 40.6%; HR 1.79, 95CI 1.75-83), male (48.3% v. 46.5%; HR 1.02 (1.01-1.04),
had developed ESRD as a result of non-resolving tubular necrosis (62.8% v. 47.8%; HR 1.25, 95%CI 1.20-
1.30), had >3 comorbidities (48.7% v. 40.7%; HR 1.25, 95%CI 1.23-1.27), had no prior nephrology care
(69.8% v. 60.9%; HR 1.14, 95%CI 1.12-1.21), had catheter access at initiation of dialysis (66.8% v. 53.6%;
HR 1.34, 95%CI 1.28-1.40), and had died of cardiovascular causes (47.9% v. 47.1%; HR 1.07, 95%CI 1.05-
1.09). After adjustment for differences in patient characteristics, one-year mortality was higher in
patients who initiated dialysis during an index hospitalization of >2 weeks (55.5% v. 41.6%; HR 1.47,
95%CI 1.44-1.49) and in which they received an intensive procedure (63.3% v. 41.6%; HR 1.78, 95%CI
1.73-1.82).
Conclusion: Inpatient initiation of chronic dialysis is very common in older patients. Life expectancy is
extremely limited in this group, particularly in those with advanced age and complicated hospital
courses. Our findings assist healthcare workers in providing anticipatory guidance to patients initiating
chronic dialysis in the inpatient setting.
44

CALIFORNIA POSTER FINALIST - RESEARCH Ajay Yadlapati, MD
Pre-Operative Cardiac Variables and Clinical Outcomes in Patients with Bilateral Lung Transplants
Ajay Yadlapati, MD; Jamil Aboulhosn, MD
Introduction: Orthotopic lung transplantation is now widely performed in patients with advanced lung
disease. As part of the pre-operative work-up of these patients, investigation of cardiac function with
echocardiography and catheterization has been long considered the norm. Patients with moderate or
severe ventricular systolic dysfunction are typically excluded from lung transplantation; however, there
is a paucity of data regarding the prognostic significance of abnormal left ventricular diastolic function.
Methods: We reviewed the characteristics of 111 patients who underwent bilateral lung transplant at
UCLA medical center from 2002-2009 in order to evaluate the prognostic significance of preoperative
markers of diastolic function, including: Invasively measured pulmonary capillary wedge pressure
(PCWP) and echocardiographic variables of diastolic dysfunction including mitral A/E>1, E/E’>13 and
A’>E’.
Results: Out of 111 patients, 62 were male (56%) and average age was 54.0 (SD = 10.5) years. Clinical
end-points included: All-cause mortality post-transplant, cardiac death post-transplant, length of
hospitalization post-transplant, and evidence of graft dysfunction. Mildly elevated pre-transplant PCWP
(16-20 mmHg) and moderate/severely elevated PCWP (>20 mmHg) were not associated with adverse
clinical events post-transplant (p=0.51 and 0.61, respectively). Traditional echocardiographic doppler
variables of abnormal diastolic function, including A’>E’ and A/E ratio>1 did not predict adverse
events. An echocardiographic marker of elevated left atrial pressure (E/E’>13) also did not predict
adverse post-transplant events.
Conclusion: Pre-lung transplant invasive and echocardiographic findings of elevated left atrial pressure
and abnormal left ventricular diastolic function do not predict adverse post-transplant clinical events.
45

CANADA POSTER FINALIST - RESEARCH Ashraf M Al Azzoni, MBBS
The Role of Critical Response Teams on Length of Stay and Patient Outcomes in the ICU
Ashraf M Al Azzoni, MBBS Nooreen Popat, MD; Lindsay Crab, MD; Jovana Yudin, MD; Mark Soth, MD.
Introduction: Long stays in the ICU are associated with high costs to the health care system, burdens on
patients and their families and, frequently, poorer long term outcomes for patients. Interventions that
reduce length of stay in the ICU are, therefore, very important. Critical care response teams (CCRT) have
been widely implemented in hospitals in the last 5 years. This study examines the relationship between
the presence of a critical response team and ICU length of stay, as well as other patient-important
outcomes.
Methods: A retrospective chart review of all unplanned admissions to the ICU at St. Joseph’s Hospital
from January 2005 to December 2009. During this period of time, the CCRT team was implemented in
the hospital and therefore patients were classified as pre- and post- CCRT admissions. Multiple variables
were recorded including patient demographics, medical history, pre- and post-ICU MODS scores
(prognostic indicator scores), and length of stay in the ICU and hospital as well as mortality.
Results: 629 patients were included. The implementation of CCRT teams resulted in a reduction in
mortality during ICU admission in patients who received a CCRT consult (Mean 1.33 vs. 1.49 in post- and
pre- CCRT patients respectively, t=2.76, p

COLORADO POSTER FINALIST - RESEARCH Alison R Landrey, MD
Shared Decision-Making in PSA Testing: The Effect of a Mailed Patient Flyer Prior to an Annual Exam
Alison Landrey MD Daniel D. Matlock MD, MPH Laura Andrews, BA Michael Bronsert, MS, PhD Thomas
Denberg MD, PhD
Introduction: Professional societies recommend that the decision to screen for prostate cancer involve
a shared discussion between patient and provider. Many men are tested without this discussion.
Prostate cancer screening decision aids increase patient knowledge and participation in PSA testing
decisions under ideal circumstances, but are often resource-intensive and elaborate. There is a need for
evaluation of pragmatic interventions that are low-cost, low-literacy and practical for widespread
distribution.
Methods: We evaluated the effect of a mailed low-literacy informational patient flyer about the PSA
test on measures of shared decision making (SDM). 303 men aged 50-74 who were scheduled for annual
health maintenance exams in two University of Colorado general internal medicine clinics were
randomized to receive the flyer vs. usual care. Primary outcomes included chart documented PSA
screening discussions and PSA testing; secondary outcomes from follow-up patient surveys include
perceived participation in PSA screening decisions, knowledge of the PSA test, and flyer acceptability.
Results: Rates of chart-documented PSA discussions were low with no difference between the flyer and
control groups (17.7% and 13.6% respectively; p = 0.28). Rates of PSA testing were also similar in both
groups (62.5% vs. 58.5%; p = 0.48). Rates of patient-reported PSA discussions were higher than the
documented rates but also without differences between the groups (71.8% vs. 62.3%; p = 0.22). The
intervention had no effect in the PSA knowledge scores (3.5/5 vs. 3.3/5, p=0.60). Patients found the flyer
to be highly acceptable.
Conclusion: A mailed low-literacy informational flyer had no effect on rates of documented PSA
discussions or PSA testing.
47

CONNECTICUT POSTER FINALIST - RESEARCH Olivia Pop, MD
De-escalating Empiric Vancomycin in Patients with Health-Care Associated Pneumonia
Olivia-Fabiola Pop MD1, Odaliz Abreu-Lanfranco MD², Whitney Hung, PharmD1, Afshin Karjoo,
PharmD1, Ann Fisher, MD1,3, John M Boyce MD1,3. ¹Hospital of Saint Raphael, New Haven CT; ²Wayne
State University, Detroit Medical Center MI, 3Yale University Sch
Introduction: Background: IDSA guidelines recommend de-escalating antibiotics in health-care
associated pneumonia (HCAP) based on lower respiratory cultures. In the absence of lower respiratory
cultures, physicians are sometimes reluctant to discontinue Vancomycin (VANC) that was initiated for
suspected HCAP due to methicillin-resistant Staphylococcus aureus (MRSA). Previous studies have
shown that the combination of nasal and throat cultures without growth of MRSA has a negative
predictive value of 97% for MRSA colonization. We studied the safety of discontinuing empiric VANC in
HCAP patients (pts) based on negative nasal and throat MRSA surveillance cultures.
Methods: In a convenience sample of pts receiving empiric VANC for suspected MRSA HCAP and in
whom no adequate lower respiratory culture was available, the antimicrobial stewardship (AMS) team
recommended obtaining nasal and throat swabs, which were inoculated onto chromogenic MRSA
selective agar. In pts with both cultures negative for MRSA and a clinical pulmonary infection score
(CPIS) less than 6, the AMS team recommended discontinuing VANC. After discontinuing VANC, charts
were retrospectively reviewed to determine if pts expired or developed culture-proven MRSA
pneumonia within 30 days.
Results: From a total number of 55 pts, vancomycin was stopped by day 5 in 43 of these based on nasal
and throat swabs negative for MRSA and a low CPIS. On the day VANC was discontinued in these 43 pts,
the CPIS was: 0 (6pts), 1 (10pts), 2 (12pts), 3(10pts), 4(5pts). None of the pts developed confirmed MRSA
pneumonia during the rest of their hospital stay, none was readmitted with a MRSA pneumonia, or
expired secondary to MRSA pneumonia. One pt was readmitted with pneumonia of unknown etiology
and was treated with piperacillin-tazobactam plus VANC. One patient who was readmitted for other
reasons expired, and an autopsy showed no evidence of pneumonia.
Conclusion: These preliminary data suggest that in the absence of a good lower respiratory culture, it is
safe to de-escalate empiric VANC in patients with suspected MRSA HCAP who have both nasal and
throat MRSA swab cultures negative and a low CPIS. Further evaluation of this strategy appears
warranted.
48

Chile POSTER FINALIST - RESEARCH Maria M Canals Cavagnaro, MD
MELD Score Predicts Mortality in Cirrhotic Patients with Spontaneous Bacterial Peritonitis
Canals M, Munita JM, Contreras J, Cordero V, Alvarez A, Miranda JP, Perez J
Introduction: Spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis has a high mortality
rate, both on acute and medium term. Thus, developement of SBP is one of the indications for liver
transplantation. The Model for End-Stage Liver Disease (MELD) score was created as a marker for
transplant need and is one of the main tools available to categorize the severity of a chronic liver failure.
Our aim was to evaluate the usefulness of the MELD as a prognosis score in cirrhotic patients developing
a SBP.
Methods: The clinical charts of all patients with liver cirrhosis and a first episode of SBP admitted at
Hospital Padre Hurtado between January 2003 and January 2008 were retrospectively reviewed. Clinical,
demographic and microbiological characteristics were obtained. Patients without enough information to
calculate the MELD score were excluded. The statistical analysis was done with SPSS 13.0. T test and Chi-
Square were used for comparison of continuous and categorical variables respectively.
Results: 70 patients were included; among them 45 (64%) were men. The mean age was 59.4+/-11.9
years and the most frequent etiology was alcohol (36/70, 51%). The mean MELD score at admission was
21+/-9 and the CHILD-PUGH A/B/C was 1/28/41, respectively. The average length of stay was 11 days (1-
41). An etiologic agent was obtained on 18/70 (26%) of cases, of which 12/70 (17%) had a positive ascitic
fluid culture and 8/44 (18%) had positive blood cultures. The most frequent organism recovered was E.
coli (8/12, 67%), followed by S. pneumoniae (2/12, 17%). Ceftriazone was the initial antibiotic therapy in
all patients and albumin was used on 26 patients. Mortality at one year was 50/70 (71%) and in hospital
mortality was 20/70 (28.5%). The mean MELD score at admission was 18.4+/-8.2 in patients who lived
and 29+/-8.1 in those who died (p

CONNECTICUT POSTER FINALIST - RESEARCH Aroonsiri Sangarlangkarn, MD
Inadequate Understanding of Code Status Improved by Case-Based Learning
Aroonsiri Sangarlangkarn MD MPH1, Margaret Drickamer MD2, 1 Yale University School of Medicine,
Department of Internal Medicine Residency Program, 2 Yale University School of Medicine, Section of
Geriatrics
Introduction: Multiple studies demonstrate continued deficiencies in physician’s education on end-oflife
care. However, there is limited literature on whether healthcare providers have an adequate
understanding of DNR/DNI, which is essential in end-of-life care and discussion. Our study aims to assess
the understanding of DNR/DNI among physicians in training and the efficacy of case-based learning in
code status education.
Methods: From September-October 2011, we surveyed medical students and residents at noon
conferences during internal medicine rotations at Yale School of Medicine, before and after a course on
challenging end-of-life cases that provide clinical applications of DNR/DNI. Constructed using the same
standards as the nationally utilized Yale Office-Based Medicine Curriculum, the course focused on
DNI/not DNR patients, reversibility of code status, and futility of care. The exact Mcnemar test was used
to evaluate changes in responses.
Results:Of 44 surveys, in DNR patients with cardiopulmonary arrest in which no interventions should be
performed, a number of participants would provide chest compression (before=9%, after=7%),
defibrillation (before=7%, after=7%), epinephrine (before=32%, after=25%), antiarrhythmics
(before=50%, after=32%), bicarbonate (before=61%, after=48%), manual lung inflation (before=48%,
after=59%), and intubation (before=59%, after=50%). In DNI patients, a number of participants failed to
offer manual lung inflation (before=64%, after=86%) and non-invasive positive pressure ventilation
(before=91%, after=93%).
After the course, participants were 9 times more likely to correctly forego antiarrhythmics in coding DNR
patients (p=0.022), and 11 times more likely to correctly offer manual lung inflation in DNI patients
(p=0.006). When asked if participants possess adequate understanding of DNR/DNI on a scale of one
(disagree) to five (agree), there was a 0.93 point increase after the course (before=3.26, after=4.19,
p=0.000). While 7% of the participants feel neutral, 93% would recommend the course to others.
Conclusion: Surveys showed that many participants would provide contraindicated interventions to DNR
patients while failing to offer appropriate intervention to DNI patients. After the course, more
participants reported having an adequate understanding of code status. A significant number correctly
withheld antiarrhythmics in coding DNR patients and appropriately offered manual lung inflation to DNI
patients. Our study showed that physicians in training may benefit from education on code status,
particularly case-based learning which may improve their understanding of DNR/DNI and the quality of
end-of-life discussion.
50

DELAWARE POSTER FINALIST - RESEARCH Chia-Shing Yang, MD
Discrepancies Between Direct Catheter and Echocardiography Based Values in Aortic Stenosis
Chia-Shing Yang, MD Chia-Shing Yang MD (Associate), Erik S. Marshall MD, Michael J Kostal MD, Joseph T
West MD, Andrew Doorey MD, Christiana Care Health System, Newark, DE
Introduction: Current guidelines for the evaluation of aortic stenosis (AS) are based on risk benefit
assessments conducted over a decade ago. Several recent studies show sizable differences between
echocardiogram and cardiac catheterization lab measurements of the aortic valve area (AVA). In our
recent practice, dyssynchrony between echocardiography-derived and catheterization-derived values
has been noticed, such that decision-to-surgery is altered. Using latest available high quality techniques,
we examined the correlation between echocardiography and catheterization-determined AVA at our
institution.
Methods: We performed sequential retrospective review of patients aged 40-90 years with suspected
AS by echo (n=42) who underwent right and left heart catheterization during 2008 to 2011. Matching
echocardiograms within 3 months of catheterization were reviewed and patients with a diagnosis of
“severe” or “critical” aortic stenosis per echocardiogram were included. Patients without precatheterization
echocardiograms were excluded. Catheterizations were conducted by two
interventional cardiologists in an academic community hospital. Valve measurements were derived from
directly measured pressure gradients via left ventricular pressure wire (St. Jude) and ascending aorta
catheter; this is in contrast to previous studies which have utilized variations of the “pull-back” method
with diagnostic catheters. Pre-catheterization 2D trans-thoracic echocardiograms were from various
institutions, obtained by a wide variety of echocardiography technicians, and read by 15 certified
cardiologists. Original echocardiogram films were independently reviewed by the investigators to assess
the quality of community-based readings.
Results: Catheterization changed assessment of AVA severity by more than 0.3cm 2 in 33% and by more
than 0.5cm 2 in 12% of patients studied. These changes in AVA values were sufficient to cross over or
under the surgical threshold (AVA

DELAWARE POSTER FINALIST - RESEARCH Chia-Shing Yang, MD
Discrepancies Between Direct Catheter and Echocardiography Based Values in Aortic Stenosis
Chia-Shing Yang, MD Chia-Shing Yang MD (Associate), Erik S. Marshall MD, Michael J Kostal MD, Joseph T
West MD, Andrew Doorey MD, Christiana Care Health System, Newark, DE
Introduction: Current guidelines for the evaluation of aortic stenosis (AS) are based on risk benefit
assessments conducted over a decade ago. Several recent studies show sizable differences between
echocardiogram and cardiac catheterization lab measurements of the aortic valve area (AVA). In our
recent practice, dyssynchrony between echocardiography-derived and catheterization-derived values
has been noticed, such that decision-to-surgery is altered. Using latest available high quality techniques,
we examined the correlation between echocardiography and catheterization-determined AVA at our
institution.
Methods: We performed sequential retrospective review of patients aged 40-90 years with suspected
AS by echo (n=42) who underwent right and left heart catheterization during 2008 to 2011. Matching
echocardiograms within 3 months of catheterization were reviewed and patients with a diagnosis of
“severe” or “critical” aortic stenosis per echocardiogram were included. Patients without precatheterization
echocardiograms were excluded. Catheterizations were conducted by two
interventional cardiologists in an academic community hospital. Valve measurements were derived from
directly measured pressure gradients via left ventricular pressure wire (St. Jude) and ascending aorta
catheter; this is in contrast to previous studies which have utilized variations of the “pull-back” method
with diagnostic catheters. Pre-catheterization 2D trans-thoracic echocardiograms were from various
institutions, obtained by a wide variety of echocardiography technicians, and read by 15 certified
cardiologists. Original echocardiogram films were independently reviewed by the investigators to assess
the quality of community-based readings.
Results: Catheterization changed assessment of AVA severity by more than 0.3cm 2 in 33% and by more
than 0.5cm 2 in 12% of patients studied. These changes in AVA values were sufficient to cross over or
under the surgical threshold (AVA

DISTRICT OF COLUMBIA POSTER FINALIST - RESEARCH Stephen Koplin
Is a Mandatory Geriatric Home Visit Acceptable to Students?
Stephen Koplin, MD, Walter Reed National Military Medical Center, Bethesda, MD (Associate) Second
Author: Gerald Denton, MD, MPH, Uniformed Services of the Health Sciences, Bethesda, MD (Fellow)
Introduction: Geriatric-specific education during medical school is an important aspect of preparing
medical school graduates for an increasingly elderly population. One method found to be effective is
the Geriatric Home Visit (GHV), which attempts to offer medical students the unique perspective of
interviewing geriatric patient in the setting of their daily life. This study aimed to determine whether a
mandatory GHV during third year medical student’s education improved medical student’s attitudes and
abilities towards geriatric care. Outcomes of this study will be used to guide further implementation of
GHV at our institution.
Methods:A mixed methods, retrospective trial was designed using exit surveys of GHV completed by
third year medical students (n=168) during their third year Internal Medicine clerkship at the Uniformed
Services University of Health Sciences (USUHS) in Bethesda, MD during the 2008-2009 academic
year. The program was designed at USUHS and were completed at 7 different military hospitals around
the US. All third year medical students were instructed to independently identify and contact an
inpatient or outpatient geriatric patient, conduct a home visit, accompanied by a fellow student,
complete a geriatric assessment and a paper describing their experiences. The exit surveys included
Likert scales and comments sections. Likert scales were analyzed using mean responses and proportion
of responses above and below the neutral point. Comments were grouped into themes using the
constant comparative method.
Results: All third year medical students were required to complete a GHV, 137 (of 168) had a survey
available for review (81.5%). 98% of the students reported feeling safe during the visit. 56% of students
felt that the GHV helped them learn and improve geriatric assessment techniques. 59% felt that the
GHV impacted the way they view geriatric patients. 77% of the students reported being adequately
prepared and 82% and 85% felt supported by their ward or clinic attendings and small group preceptor,
respectively. 32% of students had difficulty identifying geriatric patients.
Conclusion: Based on exit surveys, a mandatory GHV during the Internal Medicine rotation changed the
attitudes of third year medical students towards geriatric patients and helped them improve their
utilization of geriatric assessments. Mandatory GHV in this setting may be a useful tool in improving
knowledge and attitudes in geriatric care. Knowlege of students reactions to mandatory GHV will help
guide future development of geriatric medical care education.
53

FLORIDA POSTER FINALIST - RESEARCH Marlow B Hernandez, DO
Objective Laboratory Targets in Treatment of Patients Hospitalized for Heart Failure
Marlow B. Hernandez, DO, MPH Elsy V. Navas, MD Craig R. Asher, MD Randall Schwartz, MD Victor
Totfalusi, DO Ivan Buitrago, MD Ankush Lahoti, MD Gian M. Novaro, MD
Introduction: In the United States, the estimated prevalence of heart failure (HF) approaches 6 million
individuals, and the direct and indirect costs of HF approaches $40 billion. Despite advances in the
medical management of HF, HF remains the leading cause of hospitalizations and readmissions in the
United States. Within 3 months of hospitalization, there is a national 30% readmission rate, and 10%
mortality rate. Therefore, there is currently a focus to stratify high-risk patients with clinical indicators in
order to decrease in-hospital mortality and readmission rates.
BNP guided therapy has been shown to decrease outpatient HF related healthcare cost by nearly 25%
(totaling over $5,000 per patient, per year). The purpose of our study is to identify objective laboratory
targets that reduce re-admission rates.
Methods: Data for patients that were admitted to Cleveland Clinic Florida with principal diagnoses of
heart failure from April 1, 2010 to December 31, 2010 was retrospectively obtained via chart review. A
total of 233 patients were analyzed. Using a multivariable logistic regression analysis, the factors were
examined for statistical significance in an attempt to extract predictive factors associated with
readmission or mortality for heart failure in the 6 month period following the initial hospitalization.
Thirty day HF readmission was set as the study’s primary end point. Factors strongly linked to
readmission or mortality where examined using chi-squares and ROC curves, as applicable.
Results: The results suggest the majority of HF readmissions occur within the first 30 days of discharge
(median 9.5d, 95% CI [5d-14d]). BiV Pacemaker, ICD, higher BMI, higher sodium levels, negative fluid
balance, reduction in NT-proBNP, and normal systolic BP seem to be protective against HF readmission.
ROC curve analysis shows that fluid reduction of greater than 1.84L gives an OR of 0.36 for 30d HF
readmission. Similarly, a Na + level of greater than 136 and a NT-proBNP reduction of greater than
23% at discharge are markers of favorable HF prognosis at 30 days, with ORs of 0.40 (p < 0.05) and 0.10
(Haldane’s Estimator, p < 0.05) respectively. Meeting two or more of the above (lab) criteria goals (Fluid,
Na + , NT-proBNP) results in OR of 0.06 for HF readmission compared to patients who did not meet two of
the goals.
Conclusion: The results of this pilot study suggest that there are optimum levels of fluid reduction, NTproBNP
reduction, and sodium at discharge, in order to achieve more favorable clinical outcomes. If
clinical dispositions for acute HF inpatients are based on objective laboratory data, it may standardize
what is currently a highly variable clinical decision making process. Apart from the clinical benefits, this
approach may have significant economic benefits. The results of this study suggest that combining
biomarkers with other clinically significant inpatient variables may improve short-term HF outcomes.
54

FLORIDA POSTER FINALIST - RESEARCH Abubakr A Chaudhry, MD
Prophylactic Use of Macrolide Antibiotics for the Prevention of Exacerbations in Patients with Chronic
Obstructive Pulmonary Disease: A Meta-Analysis
Abubakr Chaudhry MD. All Authors: Elie Donath MD MPH, Leonel Hernandez-Aya MD
Introduction: Chronic Obstructive Pulmonary Disease (COPD) affects over 12 million Americans, among
which 20-30% have exacerbations annually leading to hospitalization. Multiple studies have evaluated
the use of prophylactic macrolides for the prevention of COPD exacerbations with variable results. The
purpose of our study was to conduct a meta-analysis and develop conclusive evidence regarding the
prophylactic use of macrolides in the prevention of COPD exacerbations.
Methods: EMBASE, Medline and CENTRAL databases were searched for all controlled trials in which any
type of macrolide was compared to placebo for prevention of COPD exacerbations. A total of 247
studies were identified, of which 8 trials met the inclusion criteria for the study. The primary outcome
was the relative risk of COPD exacerbation. Potentially relevant information concerning study design,
type of intervention, study population, methods of follow-up, outcomes, and methodology quality were
extracted.
Results: Using the random effects-model, the pooled estimate for incidence of COPD exacerbations
showed a 34% reduced risk (RR=.66, 95% CI: 0.54-0.0.81, p=0.001, I2=71%) of exacerbations among
patients taking prophylactic macrolides. The high I-squared value suggests significant heterogeneity
among the different outcomes. Further subgroup analyses revealed that COPD severity was an
important variable in determining effect size. Three of the trials included patients with mild/moderate
COPD and the other five trials included patients with only severe/very severe COPD. We found that
among studies that included patients with mild/moderate COPD there was a 22% reduced risk (RR=.78,
95% CI: 0.65-0.0.94, p=0.02, I2=63%) of exacerbations in patients taking macrolides. Among studies
including patients with severe/very severe COPD, there was a 42% reduced risk (RR=.58, 95% CI: 0.47-
0.0.72, p=0.01, I2=22%) of COPD exacerbations in patients taking macrolides. Of note, the I-squared was
reduced significantly through this approach. Meta-regression was employed to assess several additional
variables of interest but no definitive trends were identified. There was no consistent systematic bias
among the selected studies.
Conclusion: Administration of prophylactic macrolides to patients with COPD may be an effective
approach to decrease the incidence of COPD exacerbations. Additionally, the subgroup analysis revealed
that prophylactic macrolides may be more effective at reducing exacerbations in patients with
severe/very severe COPD compared to patients with mild/moderate COPD. There are limitations to this
study including the large degree of heterogeneity, the limited number of randomized controlled studies
identified and the inability to effectively capture the adverse effects associated with this treatment. We
urge investigators to consider undertaking more trials to assess this phenomenon further.
55

FLORIDA POSTER FINALIST - RESEARCH Elizabeth Marsicano, MD
Does Implementing a Standardized Handoff Process Improve Adherence to Best Practices and Patient
Outcomes on the General Medical wards?
Elizabeth Marsicano, MD Sharad Virmani MD, Elie Donath MD,MPH
Introduction: The ACGME’s mandate regarding new resident work hours has been met with a necessary
increase in the amount of transition of care points. This increase has led to concerns that poor quality -
handoffs can lead to increased risk to patients. The Joint Commission addressed these concerns in 2008
suggesting a standardized approach to transition of care was needed. The aim of this study was to
assess the effectiveness of integrating a standardized handoff system on self-reported adherence to
accepted best practices and patient outcomes on the general medical teaching service.
Methods: A voluntary survey, of 24 questions, was distributed to internal medicine residents in June
2011 to assess quality of their handoffs and its perceived effects on patient care (49 eligible residents,
response rate 59%). In July 2011 an educational conference emphasizing the importance of quality
handoffs, and introducing a standardized system for handoffs on the general medical floors was
held. The survey was repeated in November 2011 (64 eligible residents, response rate 43%). A Likert
scale was used to evaluate characteristics contributing to effective handoffs. Survey responses pre and
post intervention were compared using ordinal logistic regression and adjusting for resident year (PGY1-
3) and the resident’s most recent rotation (ICU vs. floors). Effect was measured using proportional odds
ratios with significance defined as p

GEORGIA POSTER FINALIST - RESEARCH Zahi Mitri, MD
Cerebrospinal Fluid Flow Cytometric Immunophenotyping in Adult Patients with Newly Diagnosed
Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma: Added Value?
Zahi Mitri, MD, Department of Internal Medicine, Emory University. Jeannine T. Holden, MD,
Department of Pathology and Laboratory Medicine, Emory University. Hanna Jean Khoury, MD,
Department of Hematology and Medical Oncology, the Winship C
Introduction: Cerebrospinal fluid (CSF) involvement by leukemic blasts occurs in fewer than 10 % of
adult patients with newly diagnosed acute lymphoblastic leukemia/lymphoma (ALL). Leukemic
meningitis is suspected when abnormal CSF protein and glucose are found. Confirmatory testing
includes red and white blood cell (WBC) counts and WBC differential, cytologic evaluation and flow
cytometric immunophenotyping (FCI). To our knowledge, no study has addressed the additional benefits
provided by CSF FCI as compared to other means of confirmatory testing in newly diagnosed patients
with ALL.
Methods: Patient demographics, disease characteristics, CSF and bone marrow findings, systemic and IT
chemotherapy treatments, complications, remission, relapse, and survival of patients with newly
diagnosed ALL were captured on study specific case report forms. CSF was classified as “positive” or
“negative” based on the presence or not of abnormal protein, glucose, and cytology. Statistics were
descriptive, performed using SPSS 16.0. The results are reported as a proportion.
Results: Between 11/2007 and 8/2011, 80 patients with newly diagnosed ALL were referred to the
Winship Cancer Institute of Emory University, all of which had CSF analysis available. Throughout the
treatment of these 80 patients, a total of 810 samples were analyzed using conventional methods, and
24 (3%) were positive and 786 (97%) were negative. Flow cytometric analyses were performed on
179/786 (23%) negative samples and 13/24 (54%) positive samples. FCI showed no aberrant cells in any
of the 179 negative samples, whereas leukemic cells were detected by in 9/13 (69%) cytologicallypositive
samples. One sample was positive using conventional methods, but FCI showed no aberrant
cells. The patient was treated as CSF negative.
Conclusion: In this study of 810 CSF samples from 80 patients with newly diagnosed ALL, FCI was found
to be of no additional utility in patients without evidence of leukemic involvement by standard criteria
of glucose and protein measurements and cell counts, as well as cytologic evaluation. One patient in
whom cytologic examination was reportedly positive for involvement by ALL were found to be negative
by FCI, and was ultimately re-classified as negative. In light of these findings, we suggest that FCI be
performed as confirmatory testing only in patients with high pre-test probability based on standard
criteria.
57

GEORGIA POSTER FINALIST - RESEARCH Vimal Ramjee, MD
Rapid Recovery of LDL after Apheresis in Patients with Familial Hypercholesterolemia: A Need for
More Frequent Treatment?
Ramjee V*, Epperson MF†, Le N-A*†, Vaughn L*, Nell-Dybdahl C*, Baer J*, Wilson PW*†, Sperling LS*.
*Emory University School of Medicine, Atlanta GA. †Atlanta VA Medical Center, Atlanta GA.
Introduction: Familial hypercholesterolemia (FH) is a rare genetic disease of accelerated atherosclerosis
due to poor plasma LDL clearance. LDL apheresis therapy is considered in patients with FH who have not
achieved lipid goals despite dietary discretion and maximum pharmacotherapy. Apheresis acutely
reduces plasma LDL cholesterol level allowing for improved cardiovascular outcomes in this population.
Current guidelines recommend one treatment every 1 to 2 weeks. The aim of this study was to better
characterize the effect of apheresis and the recovery kinetics of lipid and inflammatory markers postapheresis.
Methods: The INFLAME Study is a pilot observational, case-series clinical intervention study. Patients
with FH on maximum pharmacotherapy undergoing LDL apheresis were identified and nonconsecutively
enrolled. LDL apheresis was performed for each subject according to standard protocol
including treatment of 1.5 plasma volumes per person with dextran-sulfate cellulose adsorption
columns (Liposorber LA-15). Plasma levels of total cholesterol (TC), LDL, triglycerides (TG), and C-reactive
protein (CRP) were measured pre- and post-apheresis at multiple time points during a 48 hour inpatient
diet-controlled stay.
Results:8 FH patients (7 heterozygous, 1 homozygous; 6 female, 2 male) with a mean age of 48 ± 17
years and mean body mass index of 28.4 ± 5.2 kg/m 2 were assessed. Cardiovascular demographics of the
patients included 4 with prior myocardial infarction, 6 with coronary artery disease, 5 with carotid artery
disease, 5 with hypertension, 1 with an impaired fasting glucose, 3 with obesity, and 8 with a strong
family history of premature cardiovascular disease. Mean pre- and post-apheresis levels were: 338 and
126 mg/dL for TC, 257 and 67 mg/dL for LDL, and 2.76 and 1.05 mg/dL for CRP, respectively (p < 0.05,
all). Compared to pre-apheresis levels, mean percent recovery post-apheresis at 12, 24 and 48 hours for:
LDL was 31.1%, 37.5%, and 49.7%; and CRP was 90.5%, 134%, and 120%, respectively.
Conclusion: Our data show that LDL apheresis not only significantly decreased plasma LDL cholesterol
level, but also dramatically reduced plasma CRP. The reduction in both lipid and inflammatory
biomarkers suggests that the therapeutic effect of LDL apheresis likely goes beyond lipid pathways. Of
note, the recovery rate of LDL was rapid, returning to 50% of pre-treatment level by day 2. Given the
linear rate of LDL recovery, LDL would be expected to rebound to pre-treatment levels by day 4,
suggesting that a shorter treatment interval may provide further benefit in this population.
58

US ARMY POSTER FINALIST - RESEARCH CPT Amy N Stratton, DO
High Trough Vancomycin Therapy Guided by a Therapeutic Drug Monitoring Program Improves
Clinical Outcomes
CPT Amy N Stratton, DO (associate) Anthony Cardile, DO (associate) Gunther Hsue, MD (FACP)
Introduction: A hospital wide Vancomycin (VAN) Pharmacokinetic Service (VPS) was initiated.
Meaningful clinical outcomes data for such interventions and for high trough dosing of VAN are sparse in
the literature.
Methods: Retrospective study of 162 patients treated empirically with traditional VAN dosing practices
from July 2007 – March 2008 compared to 172 patients treated empirically with high trough VAN
therapy guided by a pharmacist managed VPS from July 2009 – March 2010. All adult patients on
intravenous VAN were included. Patients who received fewer than 4 doses of VAN, or for whom no
troughs were drawn were excluded. Data was collected in the following categories: baseline patient
characteristics, clinical outcomes, and pharmacologic monitoring. Primary outcome measures included
time to clinical stability, in-hospital mortality, and development of VAN associated nephrotoxicity.
Results: Baseline characteristics of both groups were similar. In-hospital morality, and development of
nephrotoxicity were similar among both groups. Mean time to target VAN trough was 121.7 hours in
the traditionally dosed group and 60.6 hours in the VPS group (p

ILLINOIS POSTER FINALIST - RESEARCH Jennie H Kwon, DO
"Impact of Urine Culture Colony Counts on the Diagnosis of Urinary Tract Infection (UTI) for
Hospitalized Patients"
Jennie H. Kwon DO, ACP Member, NorthShore University HealthSystem, University of Chicago, Evanston,
IL Lance R. Peterson MD, NorthShore University HealthSystem, Evanston, IL Ari Robicsek MD,
NorthShore University HealthSystem, Evanston, IL Molly
Introduction: The purpose of this investigation is to establish a colony count threshold to predict
clinically significant UTIs that develop in hospitalized patients.
Methods: A total of 185 cases were reviewed by two physicians. The primary reviewer was responsible
for data collection including subjective complaints, presence of a Foley catheter, clinical findings,
laboratory data, and whether the treating clinician diagnosed and treated a UTI. The secondary reviewer
applied the National Healthcare Safety Network (NHSN) criteria specified by the Centers for Disease
Control and Prevention for nosocomial UTI to the patient data to determine if the clinical decision made
by the treating clinician followed published guidelines for diagnosis of a healthcare-associated UTI. If
NHSN criteria were not met, then the patient was not classified as having a UTI by the secondary
reviewer. All data analysis was completed by a statician.
Results: The proportion of patients with colony counts 100,000 CFU/mL are 12.93 times more likely to be classified as having a UTI by the primary
reviewer than patients with colony counts

ILLINOIS POSTER FINALIST - RESEARCH Trinadha Pilla, MBBS
The Impact of Electronic Health Record Reminder on the Abdominal Aortic Aneurysm Screening
Gaurav Jain, MD Trinadha Pilla, MD Jacob Thomas, MD Edgard Cumpa, MD Andrew Varney, MD.
Introduction: The United States Preventive Services Task Force recommends one time screening for
Abdominal Aortic Aneurysm (AAA) by ultrasound in men aged 65 to 75 year who have ever smoked. We
assessed the quality of the AAA screening in our General Internal Medicine (GIM) clinics before and after
the introduction of a point-of-care electronic health record (EHR) reminder.
Methods: Authors conducted a chart review to assess the baseline AAA screening rate at the GIM
outpatient clinics. An intervention was implemented to incorporate a point-of-care EHR screening
reminder for all eligible patient visits. Authors reviewed charts to assess screening rates after the
intervention. The total study period was nine months. Data were collected and analyzed from preintervention
and post-intervention periods of four months each.
Results: Pre-intervention, 157 patients met the criteria of screening but only 14 (8.9%) underwent
screening. Post-intervention, 108 (54.3%) met the criteria for screening and 25 (23.1%) underwent
screening. The increase in AAA screening rate was significant (P = 0.0023).
Conclusion: A low cost and simple point-of-care EHR reminder was helpful to increase the rate of AAA
screening.
61

ILLINOIS POSTER FINALIST - RESEARCH Prantesh Jain, MD
Clinical Significance of Positive Red Blood Cell Antibody Screen with Inconclusive Antibody
Identification.
Prantesh Jain, MD Shweta Gupta MD, Harsha Poola MD, Sumedha Dhar MD, Manila Gaddh MD, Paul
Rubinstein MD, Margaret Telfer MD, Rosalind Catchatourian MD, Ram Kakaiya MD.
Introduction: The routine blood type and screen involves ABO grouping, Rh-typing and screening for
unexpected antibodies. Most of these unexpected antibodies are IgM, also known as nuisance
antibodies. They are thought not to have much clinical significance. A positive antibody screen can
sometimes be associated with inconclusive antibody identification (ABID), defined as test reactive for
gel-screen (which is a two-cell screen) with no defined pattern on ABID panel. American Association of
Blood Banking states that if an antibody screen is positive, an attempt should be made to identify the
antibody and cross-match for the same along with ABO-Rh. However, there is no literature regarding
clinical implications of the scenario where the antibody screen is positive but the ABID is inconclusive.
This study was undertaken to review this specific scenario.
Methods: All patients who had antibody screen performed with inconclusive ABID during January-2005
to December-2010 were identified from our blood-bank database and retrospectively screened for
clinical diagnosis, antibody screen, ABID, repeat screen, blood transfusions, rise in hemoglobin per unit
of packed red blood cells and occurrence of transfusion-reactions. Patients with active blood loss at the
time of screen, hemolysis or a positive antibody identified in previous screening were excluded. The
control group comprised of patients with definite positive antibody screen with an identifiable antibody,
during the same period. In our institution, the patients who have positive antibody screen get crossmatched
by gel-technology. We use Reagent Red Blood Cells 0.8% Selectogen for two-cell screen and
Reagent Red Blood Cells 0.8% Resolve panel A Antigram Antigen Profile (Ortho Clinical Diagnostics) for
defining pattern of antibodies.
Results: A total of 149 patients and 150 controls were included in the study based on above criteria. 69
(46.3%) patients from the study group had a repeat antibody screen done at a later date revealing
definite identifiable antibody in 16 (23%), negative screen in 33 (48%) and inconclusive again in 29%. 38
patients and 37 controls received transfusions. The average rise in hemoglobin per unit of red blood cell
was 1.1 g/dL in both groups. One patient in the study group had transfusion-reaction compared to none
in the control group. The transfusion reaction was a non-lethal delayed hemolytic reaction in a patient
who was subsequently identified to have “Jka” antibody at a later date. This equates to 0.7% of all
patients with inconclusive screen and 6% of patients who would have an antibody identified on
subsequent testing.
Conclusion: Patients with inconclusive ABID on positive antibody screen are usually ignored as having
not much clinical significance. Our study indicates that although transfusion appears relatively safe in
such patients, they can rarely have transfusion reactions, likely due to yet unidentified antibodies. About
a quarter of patients will have an antibody identified on subsequent testing. Hence, all patients with
inconclusive ABID screen should be tested again, to identify if an antibody is present, in order to avoid
any untoward reactions.
62

ILLINOIS POSTER FINALIST - RESEARCH Kiran Narreddy, MBBS
Are we Practicing Evidence-Based Medicine? Chlorthalidone (CTD) vs. Hydrochlorothiazide (HCTZ) to
Reduce Blood Pressure (BP) and Cardiovascular Events (CVE): A Systematic Review
Kiran Narreddy, MD Co-Author: Jean Holley, MD
Introduction: Hypertension affects roughly one in four Americans. Guidelines from the Joint National
Committee and Veteran’s Health Administration/ Department of Defense Clinical Practice Guideline on
the Management of Hypertension recommend thiazide diuretics as first line agents to treat
hypertension. None of these guidelines designate a preferred thiazide. Landmark clinical trials like
Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), Hypertension
Detection Follow-Up Program (HDFP), and Systolic Hypertension in the Elderly Program (SHEP) used
CTD- based thiazide regimens. In all these trials, CTD reduced CVE. Yet HCTZ is the most commonly
prescribed thiazide for treating hypertension. Objective: To determine if the literature shows CTD is
more effective than HCTZ in reducing BP and CVE.
Methods: A literature search in PUBMED and EMBASE (that also includes MEDLINE) using the terms “
Chlorthalidone” AND “Hydrochlorothiazide” from 1958 to 2012 identified 505 articles. 21 relevant
articles were reviewed according to our objective. Only 3 articles directly compared outcomes between
CTD and HCTZ. Two were retrospective observational cohort analyses from Multiple Risk Factor
Intervention Trial (MRFIT trial). The third was a small-randomized controlled trial of 8 weeks duration.
Results: MRFIT was a cardiovascular primary prevention trial, which enrolled 12,866 men aged 35 to 57
years. Systolic BP and CVE were measured yearly. CVE were lower in those on CTD (adjusted hazard
ratio: 0.51 [95% CI: 0.43 to 0.61]; P

ILLINOIS POSTER FINALIST - RESEARCH Vijaya Sivalingam Ramalingam, MD
Trellis thrombectomy - A Novel Endovascular treatment of Acute Deep Vein Thrombosis
Vijaya Sivalingam Ramalingam, MD Other Authors: Ramapriya Sinnakirouchenan, MD, Gary Kerber, MD
Introduction: Deep vein thrombosis (DVT) is a major clinical problem in the United States affecting
500,000 to 2 million people per year. Post thrombotic syndrome (PTS) affects at least 30% of them and
has an adverse impact on quality of life. Aggressive endovascular treatment of acute DVT has been
shown to decrease the incidence of PTS. We report the successful utilization of Trellis thrombectomy, an
isolated pharmacomechanical thrombolysis (iPMT) method, in reducing thrombus load.
Methods: Retrospective analysis was performed of all consecutive patients (n=8) treated with Trellis
thrombectomy from August 2009 to October 2010. We identified 3 patients with acute DVT, 4 patients
with acute on chronic DVT and 1 patient with AV graft thrombus. Concurrent therapies included
retrievable inferior vena cava filter insertion (n=7) and angioplasty and stenting (n=6). The primary
endpoint was restoration of rapid inline venous flow. The secondary endpoint was thrombus clearance.
Results: Restoration of rapid inline venous flow was achieved in all cases. Thrombus removal was
greater than 95% in all patients without pre-existing thrombus (n=4). A follow up duplex ultrasound at 6months
demonstrated patent venous system in them. In patients with acute on chronic DVT (n=4),
thrombus removal was 50%-95% in 2 patients and less than 50% in 2 other patients. There were no
major complications.
F - female; M - male; @ - acute on chronic DVT
III – greater than 95% thrombus removal; II – 50%-95% thrombus removal; I – less than 50% thrombus
removal
Age/Sex Extent of thrombus Grade of
thrombolysis
68/F Right forearm AV graft III Negative
27/F Left iliofemoral III Negative
23/F Left iliofemoral III Negative
19/M Right iliofemoral III Negative
71/F @ Left iliofemoral II Positive
63/F @ Left iliofemoral I Positive
58/M @ Right iliofemoral II Positive
22/F @ Right iliofemoral I Positive
64
Evidence of DVT with duplex ultrasound
at 6 months

Conclusion: Aggressive endovascular treatment of acute DVT has been shown to reduce the thrombus
load, eliminate venous obstruction, improve valvular function, decrease the incidence of PTS and
thereby improve quality of life. Both systemic and catheter directed thrombolysis have significant
bleeding complications and prolonged hospital stay. iPMT using the Trellis device is a useful alternative.
It involves passing a double balloon catheter through the clot, positioned such that a balloon is inflated
on either side of the clot. This limits the systemic release of the thrombolytic drug and allows for use of
a smaller dose. Further mechanical oscillation of the catheter ensures complete lysis of the clot which is
then aspirated. Our study demonstrates the Trellis system to be a safe and feasible single-session PMT
method for the treatment of acute DVT. It is also found to be more beneficial in patients with acute
thrombus than in patients with acute on chronic thrombus.
65

ILLINOIS POSTER FINALIST - RESEARCH Sangeetha Reddy
Clinical and Genetic Predictors of Weight Gain in Patients Diagnosed With Breast Cancer
Sangeetha Reddy, Maureen Sadim, Virginia Kaklamani
Introduction: In contrast to other cancer patients, many patients diagnosed with breast cancer gain
weight after diagnosis. In addition to decreased quality of life, obese patients have decreased response
to chemotherapy, increased cancer recurrence, and higher all-cause mortality. Our study was designed
to identify factors that contribute to weight gain in patients diagnosed with breast cancer.
Methods: A total of 565 patients diagnosed with breast cancer were prospectively and retrospectively
recruited. Chart review was conducted to obtain weights and BMIs over an 18 month period from
diagnosis. The medical record was searched for tumor characteristics (ER/PR/HER2 status, grade,
presence of LN metastases, stage), demographics (age, race), clinical factors (menopausal status), and
treatment regimens (chemotherapy use and type, hormone therapy use and type, radiation therapy
use). Blood samples were genotyped for polymorphisms in FTO (fat mass and obesity-associated
protein) and the adiponectin pathway, two pathways found to be associated with obesity and breast
cancer risk.
Results: The average age of patients at diagnosis was 51 years (range 26-87). The percentage of patients
gaining weight after diagnosis was 53.0% at 3-6 month follow-up, 60.2% at 1 year, and 68.1% at 18
months. In univariate analysis, the following variables were found to be significant for increase in BMI:
LN metastases (p=0.01 at 6 mo, 0.03 at 1 year), positive ER status (p

KENTUCKY POSTER FINALIST - RESEARCH Thorsten M Leucker, MD
Endothelial Derived Cardioprotection Is Abolished By Hyperglycemia
Thorsten M. Leucker, MD, Phillip F. Pratt Jr., PhD, David C. Warltier, MD, PhD, Judy R. Kersten, MD and
Steven P. Jones, PhD
Introduction: Previous experimental findings elucidating mechanisms of endogenous cardioprotection
have focused predominately on the cardiomyocyte (CM) and little attention has been paid to the
specific contribution of endothelial cells (EC) to CM protection. CM are surrounded by a complex
network of capillaries and depend on EC not only for nutritive function, but are also influenced by ECderived
paracrine factors (e.g. NO) that may promote CM survival. Conversely, endothelial dysfunction
presents during various disease states such as diabetes, hypercholesterolemia or hypertension may
disrupt favorable EC-CM interactions.
Methods: EC were cocultured with CM at different ratios (1:3, 1:6, 1:12) and subjected to 120 min of
hypoxia followed by 120 min of reoxygenation (H/R). Equal numbers of CM were used in all
experimental groups. EC-CM ratio of 1:3 showed the most pronounced CM protection (LDH release
coculture 21.7±0.9 fold change to normoxic control vs. 82.4±3.8 in CM alone). EC alone, subject to H/R
did not significantly contribute to LDH release. EC-derived cardioprotection was abolished by 1 mM
LNAME (85±9.5% of CM alone) or by prior incubation of EC in hyperglycemic media (81±1.7% of CM
alone). Interestingly, the addition of 50 mM sepiapterine, a substrate for tetrahydrobiopterin (BH4)
synthesis, reversed (25±2.3% of CM alone) the detrimental effect of hyperglycemia and restored the
protective properties of EC in coculture.
Results: Our data demonstrates the importance of EC-derived factors in protection of CM against
ischemia reperfusion (I/R) injury. The observation that protection was attenuated by NOS inhibition or
high glucose supports the concept that EC derived NO is a key element involved in cardioprotection.
Diabetes and hyperglycemia have been shown to decrease bioavailable NO and the restoration of ECderived
CM protection with sepiapterine suggests that cardioprotection is also BH4-dependent.
Decreases in BH4 contribute to EC dysfunction in diabetes, whereas, BH4 supplementation decreases
ROS production and restores EC function induced by acute hyperglycemia and diabetes.
Conclusion: Elucidating the role of EC-CM interactions during I/R injury suggests new therapeutic
approaches to the treatment of patients with diabetes and dysfunctional endothelium.
67

MARYLAND POSTER FINALIST - RESEARCH Mohit Girotra, MBBS
Serum Hsp70: A Novel Pancreatic Cancer Biomarker
1Mohit Girotra, 1Montish Singla, 1Anand Dutta, 2Padmanabhan P Nair, 3Nipun B. Merchant, 4Sudhir K.
Dutta 1Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD 2Professor,
Johns Hopkins Bloomberg School of Public Health, Ba
Introduction: Heat shock proteins (HSPs) are intracellular polypeptides which are induced in response to
a variety of stimuli, and act as molecular chaperones carrying out several housekeeping functions in the
cell. HSP70 is overexpressed in human pancreatic cancer cell lines. The study was designed to determine
if serum HSP70 levels are elevated in patients with pancreatic cancer and can function as a biomarker
for early detection of pancreatic cancer.
Methods: Study subjects were divided into 3 groups – histologically proven pancreatic cancer (PC,
n=23), chronic pancreatitis (CP, n=12) and matched normal control subjects (C, n=10). Serum HSP70
levels were determined utilizing a novel immunoelectrophoresis method developed and validated by the
authors. Significance of difference between the groups was analyzed with Analysis of Variance test
(ANOVA). Receiver operating characteristic (ROC) curve analysis was performed to discriminate
pancreatic cancer patients from normal controls.
Results: The mean ± SE serum HSP70 levels in PC, CP and C groups were 1.68±0.083ng/ml,
0.40±0.057ng/ml and 0.04ng/ml respectively. Serum HSP70 levels in PC group were significantly higher
compared with either the CP or C groups (p

MARYLAND POSTER FINALIST - RESEARCH CPT Johnny A Dias, MC USA
Comparison of Aerosolized Swallowed Fluticasone to Esomeprazole for the Treatment of Eosinophilic
Esophagitis
Johnny A. Dias, DO (Associate), Ganesh R. Veerappan, MD, FACP, Corinne Maydonovitch, BS, Roy K. H.
Wong, MD (Fellow), Fouad J. Moawad, MD (Member)
Introduction: To compare the histologic and clinical response of patients with eosinophilic esophagitis
(EoE) treated with aerosolized swallowed steroids versus proton pump inhibitors (PPI).
Methods: This prospective single-blinded randomized controlled trial enrolled newly diagnosed EoE
patients in a treatment protocol. EoE was defined as patients with both clinical symptoms (dysphagia
and food impaction) and meeting histologic criteria (>15 eosinophils/HPF). Patients underwent 24-hour
pH/impedance monitoring to establish coexisting gastroesophageal reflux disease (GERD). Patients were
then randomized to aerosolized swallowed fluticasone 440 mcg twice daily (FLU) or esomeprazole 40 mg
by mouth daily (ESO) for 8 weeks. Primary outcome was resolution of esophageal eosinophilia defined
as < 7 eosinophils/HPF. Secondary outcomes included clinical assessment using the validated Mayo
dysphagia questionnaire (MDQ), endoscopic findings, and other histologic markers. Nonparametric
statistics were used for statistical analysis.
Results: 42 patients (90% male, 81% white, mean age 38+10 years) were randomized into FLU (N=21)
and ESO (N=21) treatment arms. 19% (8/42) of EoE patients had coexisting GERD and were equally
stratified into each arm (N=4). Overall, resolution of esophageal eosinophilia was similar between FLU
and ESO (19% vs. 35%, respectively, p=0.247). The adjusted MDQ score before and after therapy
significantly improved in the ESO group (19 + 21 vs. 1+5, p

MARYLAND POSTER FINALIST - RESEARCH Katrina A Abadilla, MD
Impact of Cyp2c19*2 Versus *3 Loss-of-function Allele on Response to High Maintenance-dose
Clopidogrel in Patients Undergoing Percutaneous Coronary Intervention
Katrina A. Abadilla, MD; Ily Kristine T. Yumul, MD
Introduction: The U.S. FDA highlighted the role of genotyping in clopidogrel pharmacokinetics and
clinical efficacy, and recommended the use of alternative treatment or treatment strategies in carriers
with 2 loss-of-function (LoF) alleles of CYP2C19 gene (poor metabolizers). Whether doubling the
maintenance dose of clopidogrel can provide adequate antiplatelet effect in the CYP2C19 poor
metabolizers can be an important issue for personalized antiplatelet therapy.
The prevalence of the CYP2C19 LoF variant is 55-70% among East Asians, which is much higher
compared with Caucasians (25-35%). Also, 10-20% of Asians carry CYP2C19*3 allele, scarcely observed
in Caucasians, and prevalence of poor metabolizers is 10-20% vs. ~5% in East Asians vs. Caucasians.
We sought to assess the additive antiplatelet effect by doubling of clopidogrel dose depending on the
CYP2C19 metabolic phenotype in PCI-treated East Asian patients. In addition, we compared the impact
of the CYP2C19*2 and *3 LoF alleles on response to clopidogrel regimens.
Methods: One hundred fifty five patients from a registry of the ACCEL (Adjunctive Cilostazol versus High
Maintenance-dose ClopidogrEL) studies were collected. Elective percutaneous coronary intervention
(PCI)-treated and acute myocardial infarction (AMI) post-emergent PCI patients were all on chronic
clopidogrel therapy (75 mg > 5 days) prior to randomization. The current cohort then received
clopidogrel 150 mg daily and aspirin 200 mg daily for 30 days. Adenosine diphosphate (ADP) (5 and 20
µM)-induced platelet aggregations (PA) (maximal and 5-minute final) were evaluated using the AggRAM
aggregometer. Genotyping for the CYP2C19*2/*3 variants was performed.
Results: In this cohort, 63.9% of the total (n = 99) were carriers of the CYP2C19 LoF allele (*2 or *3):
47.1% (n = 73) and 16.8% (n = 26) were intermediate and poor metabolizers, respectively. Platelet
reactivity and the prevalence of high on-treatment platelet reactivity increased proportionally according
to the number of the CYP2C19 LoF allele, irrespective of regimens of clopidogrel treatment. In contrast
to extensive and intermediate metabolizers, the poor metabolizers showed significantly lower decreases
on platelet measures (P

MARYLAND POSTER FINALIST - RESEARCH Subhash Chandra, MD
Inpatient Mortality in Urban Community Hospital; A Contribution from Clostridium difficile Infection
Subhash Chandra, MD Vankataraman Palbindala, Alamalumanglapurum Bharath, Nyan Latt, Ujjval
Jariwala, Rameet Thapa, Margrita Noel, Surendra Marur, Niraj Jani Raman Palabindala,
Alamelumangralpuram Bharath
Introduction: Reported mortality and morbidity attributed to Clostridium difficile infection (CDI) is rising,
especially in reports after the year 2000. It is partially explained by increasing hospitalized patient age
and appearance of more virulent strains. In this descriptive study, we are reporting trends of all cause
inpatient mortality and the contribution from CDI.
Methods: This retrospective descriptive study was conducted in a 360-bed urban community hospital.
All patients admitted to the medical service during September 2005 to September 2011 were included in
the study. Patients who chose hospice care were excluded from data-analysis. Primary outcome
measured was all cause mortality in the hospital. The diagnosis of CDI was established by combination of
clinical suspicion and stool specimen positive for Clostridium difficile toxin.
Results: Of 52,068 patients admitted to the medical service, 2,282 chose hospice care. All cause
inpatient deaths were 1037 (2.1%), out of those 34 (3.3%) had CDI during hospitalization. All-cause
inpatient deaths were significantly higher in patients with CDI 8.7% vs 2.0%, p

MARYLAND POSTER FINALIST - RESEARCH CPT Johnny A Dias, MC USA
Comparison of Aerosolized Swallowed Fluticasone to Esomeprazole for the Treatment of Eosinophilic
Esophagitis
Johnny A. Dias, DO (Associate), Ganesh R. Veerappan, MD, FACP, Corinne Maydonovitch, BS, Roy K. H.
Wong, MD (Fellow), Fouad J. Moawad, MD (Member)
Introduction: To compare the histologic and clinical response of patients with eosinophilic esophagitis
(EoE) treated with aerosolized swallowed steroids versus proton pump inhibitors (PPI).
Methods: This prospective single-blinded randomized controlled trial enrolled newly diagnosed EoE
patients in a treatment protocol. EoE was defined as patients with both clinical symptoms (dysphagia
and food impaction) and meeting histologic criteria (>15 eosinophils/HPF). Patients underwent 24-hour
pH/impedance monitoring to establish coexisting gastroesophageal reflux disease (GERD). Patients were
then randomized to aerosolized swallowed fluticasone 440 mcg twice daily (FLU) or esomeprazole 40 mg
by mouth daily (ESO) for 8 weeks. Primary outcome was resolution of esophageal eosinophilia defined
as < 7 eosinophils/HPF. Secondary outcomes included clinical assessment using the validated Mayo
dysphagia questionnaire (MDQ), endoscopic findings, and other histologic markers. Nonparametric
statistics were used for statistical analysis.
Results: 42 patients (90% male, 81% white, mean age 38+10 years) were randomized into FLU (N=21)
and ESO (N=21) treatment arms. 19% (8/42) of EoE patients had coexisting GERD and were equally
stratified into each arm (N=4). Overall, resolution of esophageal eosinophilia was similar between FLU
and ESO (19% vs. 35%, respectively, p=0.247). The adjusted MDQ score before and after therapy
significantly improved in the ESO group (19 + 21 vs. 1+5, p

MARYLAND POSTER FINALIST - RESEARCH Dhavalkumar Patel, MBBS
Discordant Effect of CRP Levels on Cardiovascular Events and Angiographic Progression of
Atherosclerosis- Data from Women's Angiographic Vitamin and Estrogen (WAVE) Trial.
Dhavalkumar Patel MD MPH, Soha Ahmad MD, Zhenyi Xue MS, Angela Silverman MS, Joseph Lindsay
MD FACP FACC
Introduction: The association between CRP, a marker of inflammation, and higher cardiovascular events
had been shown in many clinical studies. However, it is unclear that cardiovascular risk associated with
CRP is due to arterial narrowing or due to formation of unstable plaque. The aim of our study is to
determine the effect of baseline CRP levels on cardiovascular events and angiographic progression of
atherosclerosis among post menopausal women.
Methods: 423 postmenopausal women, with documented angiographic stenosis between 15 -75%, were
randomized in the WAVE trial to Vitamin C and E or placebo and hormone replacement therapy or
placebo. This was a negative study, but did provide baseline and follow up (mean= 2.8 years)
angiographic data in 320 women. Women were stratified into two groups (lower three quartiles and
upper quartile) according to baseline CRP levels. The Changes in lumen diameters and clinical events
were compared between groups. Differences between continuous variables were tested with student’s
independent t-test and differences between categorical variables were compared using chi-square test
or fisher’s exact test. Confounding factors were adjusted using linier and logistic regression analysis to
determine independent effect of CRP levels on angiographic luminal narrowing and clinical events.
Results: Women in lower three quartiles have CRP level

MASSACHUSETTS POSTER FINALIST - RESEARCH Aparna Raj, MD
Chapter Winning Abstract
Aparna Raj, MD, Naomi Ko, MD, Tracy Battaglia, MD, MPH, and Beverly Moy, MD, MPH
Introduction: Elimination of disparities is critically important for lessening the burden of cancer. Patient
navigator programs (PNPs) assist with all aspects of care, including access, cancer prevention, screening,
post-diagnosis care, and survivorship care. Little is known about the effect of PNPs on patient care and
outcomes following the diagnosis of breast cancer (BC). We examined quality measures (QMs) of breast
cancer care among women participating in the Massachusetts General Hospital Avon Breast Care Patient
Navigator Program (MABCP), which provides patient navigation services to disadvantaged minority
communities in the greater Boston area.
Methods: Women diagnosed with BC who participated in the MABCP from 2001 to 2011 were followed
to determine the proportion whose care was concordant with American Society of Clinical
Oncology/National Comprehensive Cancer Network (ASCO/NCCN) QMs. QMs included 1) hormonal
therapy (HT) within 1 year of diagnosis for HR+ tumors > 1 cm; 2)chemotherapy within 120 days of
diagnosis of HR- >1cm tumors for women

MASSACHUSETTS POSTER FINALIST - RESEARCH Shihab Masrur
Predictors of the Use of Dysphagia Screening in Patients with Acute Ischemic Stroke
Shihab Masrur, Eric E. Smith, Jeffrey L. Saver, Mathew J. Reeves, Deepak L. Bhatt, Xin Zhao, Wendy Pan,
Adrian F. Hernandez, Gregg C. Fonarow, Lee H. Schwamm
Introduction: Pneumonia is a potentially devastating complication of stroke. A simple bedside dysphagia
screen (DS) protocol can be used by healthcare providers to detect risk of aspiration in acute ischemic
stroke (AIS) patients. We sought to identify those characteristics of acute ischemic stroke (AIS) patients
associated with use of DS prior to any oral intake in the Get With The Guidelines-Stroke (GWTG-S)
program.
Methods: Data from 1256 GWTG-S hospitals from 04/01/2003 to 03/30/2009 were analyzed. DS was
defined as the use of a bedside swallow screen prior to any oral intake. Patients who were kept strictly
without oral intake (NPO) the entire hospital stay were excluded. Univariate analyses (chi-square for
categorical variables or Wilcoxon for continuous variables) and multivariate logistic regression analyses
were performed to identify independent factors associated with use of DS in AIS patients. In multivariate
analyses, NIHSS was not included due to high rates of missing data (55%).
Results: Among 446,056 ischemic stroke patients, 300,874 (67.4%) had DS performance documented.
When compared with patients without DS, those with DS were slightly older, had higher NIHSS (when
measured) and more frequently arrived by EMS and had a history of atrial fibrillation. They were less
often diabetics, and had similar rates of prior stroke/TIA, dyslipidemia, PVD, and current
smoking. Among patients with mild stroke (NIHSS

76
South vs. West 1.03 0.86 1.23 0.77
Variables in the initial model: patient characteristics of age, gender, race, multiple medical history (2 or
more of medical history of Afib, stroke/TIA, CAD/prior MI, carotid stenosis, diabetes, PVD, hypertension,
dyslipidemia, smoking), hospital characteristics of region, number of beds, academic vs. not. Variables
with p-value > 0.1 in the full model were removed.
Conclusion: National guidelines recommend DS before any oral intake in all AIS but the overall rate
remains low (67.4%). Patients with increased age, multiple comorbidities, at academic hospitals, or in
certain regions are more likely to get DS. Further studies are needed to identify barriers and propose
strategies to increase the routine use of dysphagia screening among all stroke patients.

MASSACHUSETTS POSTER FINALIST - RESEARCH Sandeep R Somalaraju, MBBS
Analysis of Chlamydia Infection Management -- a Quality Improvement Initiative
Sandeep R. Somalaraju, M.D (Associate) Second Author: Maria Fahey, R.N Third Author: Alwyn Rapose,
M.D
Introduction: Sexually transmitted infections (STIs) are a major public health challenge, chlamydia being
the most common, with 1.2 million cases reported to the CDC in 2009. Optimal management of
chlamydia by community practitioners is imperative in disease control, and the CDC has established
guidelines for appropriate testing, therapy, as well as partner notification and testing. Management of
patients with chlamydia presenting to a multispecialty group practice was analyzed by the Infection
Control Committee as one of its Quality Improvement measures.
Methods: A retrospective chart review of patients with positive laboratory testing for chlamydia from
October 2010 - March 2011 was performed. Data abstracted included demographics, medication
prescribed, documentation of counseling recommending partner testing, and follow-up testing of index
cases within a time frame of 3-12 months.
Results: 74 patient charts were reviewed, of which 59 were from adult primary care clinics, 14 from
pediatric clinics and 1 from OB/GYN clinic. Compliance was 100% with prescription of the
recommended regimen for antibiotic treatment (81% patients received azithromycin; 19% received
doxycycline), whereas test for cure was 92% having been booked for repeat testing within a 3-12 month
follow-up. Counseling for partner testing was documented in 81% of patients.
Conclusion: In this retrospective analysis we found that community practitioners in this multispecialty
group were 100% compliant with the CDC recommended treatment regimen. In regards to follow up, a
very high percentage of patients were scheduled for follow up testing to ensure cure, thus indicating
that the majority of the physicians in this group practice were aware of this guideline. However,
counseling for partner notification and testing was an area that needed improvement.
While the appropriateness of chlamydia treatment in the form of antibiotic use was optimal, the
Infection Control Committee recommended further education of the practitioners of the CDC guidelines
regarding follow up testing of the index case and partner notification. This recommendation as a target
for Quality Improvement in the clinic was forwarded to the Medical Director for Quality and Patient
Safety.
77

MICHIGAN POSTER FINALIST - RESEARCH Mostafa O El-Refai, MBBCH
Fluid Balance as a Predictor of Readmission in Patients with Acute Decompensated Heart Failure
Mostafa El-Refai, MD; Nikhil Ambulgekar, MD; Mario Njeim, MD; Waqas Qureshi , MD
Introduction: Acute decompensated heart failure is one of the most common admitting diagnoses. It is
unclear whether the documentation of fluid balance, which is sometimes incomplete, leads to any effect
on readmission rates of these patients. The aim of this study is to assess the impact of fluid balance
documentation as a predictor of 30 day readmission in heart failure patients.
HYPOTHESIS: Complete documentation of daily fluid balance leads to a decrease in 30 day readmission
rate and early discharge of the patients.
Methods: We retrospectively reviewed data on 350 patients admitted to the hospital from January 2009
till December 2009,that were discharged with a primary discharge diagnosis of heart failure. Out of
these, 38 patients were excluded since they were enrolled into hospice or required Milrinone therapy
during the admission. We collected data on 312 patients regarding 70 clinical and echocardiographic
variables that we thought might predict readmission. Complete documentation was defined as
documentation of fluid balance in the first 24 hours of admission.
Results: The mean age was 67.7 ± 16.8 years with 152 (48.7%) women. The patients were not different
at baseline in regards to age, gender, race, prevalence of diastolic heart failure, and use of other forms
of diuretics. On the other hand, they were found to be different in regards to ejection fraction, dose of
furosemide at discharge, daily dose of furosemide. A total of 173 (55.4%) were identified to have
complete documentation. 92 (29%) of the patients were readmitted for heart failure. There was no
difference in readmission rates of both groups but the length of stay was longer for patients with
complete documentation. The mean doses of all forms of furosemide were higher in patients with
complete documentation. Physician made more changes in the diuretic regimen, more x-rays were
ordered, and more Foley's catheters were placed in the complete documentation group all with
statistically significant P-values.
Conclusion: The study highlights that accurate fluid balance documentation is not associated with a
decrease in readmission rate but it may help us in many other decisions related to management of the
hospitalized heart failure patient.
78

MICHIGAN POSTER FINALIST - RESEARCH Shwan Mohamod Ohahir Jalal,
MBChB
Candida glabrata Fournier's Gangrene
Shwan Mohamod Dhahir Jalal, MD, MBChB, Laurence Briski MD, Joel T. Fishbain MD
Introduction: Fournier’s gangrene is an aggressive necrotizing skin and soft tissue infection of the
perineum. The disease is more prevalent in patients with diabetes mellitus and has been associated with
urological or anorectal manipulation. Infections are most often polymicrobial and represent normal flora
of the gastrointestinal tract as well as Staphylococcus aureus. Infections due primarily to Candida
species are extremely rare and the finding non-albicans species even more so.
Methods: Our patient was a 62 year old gentleman with past medical history significant for diabetes,
hypertension, chronic kidney disease, cardiomyopathy and peripheral vascular disease. He was brought
in to the Emergency Department because of altered mental status, scrotal pain, swelling and redness for
the past 2-3 days. No fevers, chills or night sweats were reported. There was no recollection or report of
trauma and he did not have chronic Foley catheter. His physical examination was remarkable for lack of
fever and stable vital signs. His scrotum was markedly inflamed with induration, tenderness to minimal
palpation but no obvious fluctuance, bullae, necrotic tissue or crepitus was appreciated. His blood sugar
was 550, WBC count was 19,000 cells/mm3 and urinalysis showed 736 WBCs and large leukocyte
esterase. CT scan revealed soft tissue stranding in the perineum with air in the inguinal canal. The
patient was taken to the operating room and underwent debridement. Intra-operative findings were
notable for necrosis and some purulent fluid. Blood, urine and operative room cultures all yielded pure
cultures of Candida glabrata.The patient was initially treated with broad spectrum antibiotics but
therapy was changed to fluconazole (urinary tract penetration) and micafungin (soft tissue penetration).
The patient did well with additional wound care and debridement.
Results: Fournier's gangrene is a necrotizing fasciitis of genitalia and perineum that mainly involves
subcutaneous tissues. First described in 1883 by French dermatologist Jean Alfred Fournier. The disease
can rapidly progress and It must be managed as a life-threatening emergency because of associated
mortality. There are multiple risk factors that can predispose to Fournier's gangrene. The infection is
typically polymicrobial in nature. Management includes aggressive medical treatment with broad
spectrum antibiotics and immediate surgical debridement of all necrotic tissue. Follow-up debridment is
recommended as a second look procedure. Our case represents the unusual occurrence of a single
pathogen (previously only reported in 3 cases). Because C. glabrata may be resistant to fluconazole
(testing was not readily available), this patient received an echinocandin for treatment. The presence of
the organism in the urinary tract, however, required the addition of fluconazole due to poor urine levels
of echinocandins.
Conclusion: Fournier’s gangrene is a life threatening condition which results in significant morbidity and
mortality. Early recognition with aggressive surgical debridement and appropriate antimicrobial therapy
is the mainstay of therapy. Our case represents a rare occurrence of a single pathogen whose presence
is also rarely reported (C. glabrata).
79

MICHIGAN POSTER FINALIST - RESEARCH Raid Ahmad Abu-Awwad, MD
Telemonitoring in Patients with Heart Failure: A Single-Center Experience
Raid Ahmad Abu-Awwad MD. All Authors: Yaser Alkhatib MD, Aymen Bukannan MD, Ghassan Bandak
MD, Mazen El Atrache MD, Jacqueline Pflaum MD, Mohammad Zaidan MD, Kimberly Baker-Genaw MD.
Department Of Internal Medicine, Henry Ford Hospital.
Introduction: Despite advances in medical treatment for heart failure (HF), rates of death and
readmission after hospitalization remain high and impact the entire health system resources. Recently,
two large randomized controlled studies showed that telemonitoring does not intrinsically carry a
significant benefit in terms of improving HF outcomes. This contradicts with the findings of previous
systematic reviews and meta-analyses of small scale studies which showed benefits of such strategy.
The aim of our study is to assess the benefits of adopting such strategy in a focused, patient centered
team care clinic as opposed to the large multicenter studies.
Methods: The study was a retrospective chart review and analysis of 212 patients who were enrolled in
the "The Heart Failure Tele-Assurance Program" at tertiary medical center between the years 2007 and
2011. Only patients with at least 6 months of adherence to the program after enrollment were included
in the study. Analysis included data collected over a time period of 6 months prior to enrollment
through 6 months after enrollment. The primary end-points were number of hospitalizations,
emergency department (ED) visits and clinic visits, for any reason. Secondary end-points included
hospitalization for HF, admission to the intensive care unit (ICU) and number of days in the hospital.
Comparison of pre-enrollment data to post-enrollment data was done using Wilcoxon signed-rank tests.
Results: Of the 212 patients that were included in the study, mean age was 71, 51% were female, and
78% were African-American. Mean ejection fraction (EF) was 41%. There were significantly fewer overall
hospitalizations, ED visits and clinic visits 6 months post-enrollment [decrease of 38% (p

MICHIGAN POSTER FINALIST - RESEARCH Mohammed N Kanaan, MBBS
Standardization for Lymphatic Mapping in Breast, Melanoma and GI Cancers - An International
Medical Survey.
Mohammed N Kanaan, MBBS* , David Wiese, MD, PhD*, Yuko Kitagawa, MD, PhD**, Markus Zuber,
MD, PhD***, Madan Arora, MD*, Sukamal Saha, MD* *McLaren Regional Medical Center, MI, USA
**Keio University, Japan *** Kantonsspital Center, Sweden
Introduction: The technique of Sentinel Lymph Node Mapping (SLNM) varies between surgeons,
centers/hospitals and countries in terms of type and amount of dye, pathologic examination of SLN,
technical issues of dye injection. The purpose of this study is to evaluate the methods of lymphatic
mapping in solid tumors around the world to create a form of international reference for all oncologists
to use for patients with breast, melanoma and GI cancers.
Methods: A web-based survey form was created with 12 questions in regards to various aspects of
SLNM for melanoma, breast, esophagus, stomach, colon and rectal cancers. This questionnaire was
distributed to 425 centers in the U.S, 60 in Europe, and more than 60 in Japan. After the initial
distribution in April 2010, the survey was re-submitted twice. By the end of June, 2011, the data was
calculated for further analysis.
Results: Out of the 545 centers that received the survey, 122 centers (22.3 %) responded. Of these 47
are from U.S, 60 from Japan, and 15 from Europe. There are 13 centers that do not use lymphatic
mapping. The order of frequency of the organ sites for lymphatic mapping was as follows: breast (80
centers), melanoma (53 centers), stomach and esophagus (24 centers), and colorectal (19 centers).
There were 56 centers that perform SLNM on one organ site, 39 perform on 2 organ sites, and 14
centers perform on 3 organ sites. The most common mapping agents used for SLNM was Radiocolloid
(breast 80%, melanoma 90%, upper GI 66% and colorectal 42%). For breast, the most common site of
injection was subareolar, while in upper GI submucosal, and in lower GI it was subserosal. Overall the
average volume of injection for lymphatic mapping was 1-2 ml (range 0.4-5 ml). Pathological
intraoperative interpretation varied from 74% in breast, 38% in melanoma, and 42% in upper GI and
26% in lower GI.
Conclusion: The technique of Sentinel Lymph Node Mapping (SLNM) varies between surgeons,
centers/hospitals and countries in terms of type and amount of dye, pathologic examination of SLN,
technical issues of dye injection. The purpose of this study is to evaluate the methods of lymphatic
mapping in solid tumors around the world to create a form of international reference for all oncologists
to use for patients with breast, melanoma and GI cancers.
81

MICHIGAN POSTER FINALIST - RESEARCH Javier Neyra, MD
De Novo Dipstick Proteinuria (DP) as Predictor of Acute Kidney Injury (AKI) in Critically Ill Septic
Patients
Javier Neyra, MD George Maidaa, MD John Manllo, MD Gordon Jacobsen, MS Jerry Yee, MD, FACP, FASN
Introduction: AKI occurs in nearly 30% of patients with severe sepsis and microalbuminuria has been
described in up to 87% of septic patients.
Methods: In order to determine the predictive value of de novo DP as an early biomarker of sepsisassociated
AKI, we retrospectively analyzed data from patients with severe sepsis admitted to our
institution’s intensive care units between 01/2004 and 07/2011 for DP. Exclusion criteria included a
baseline serum creatinine (SCr) level > 1.5 mg/dL, presence of DP within 3 months of the index
admission date and common causes of false-positive DP, e.g., urinary tract infection or gross hematuria.
Results: A total of 2,252 patients were screened and 470 were included in the study. Of these, 328
patients underwent DP-testing at admission. The SCr increased > 0.3 mg/dL in 210 (64%) subjects within
the first 72 hours of admission. In this group, new onset DP was found in 114 (54%) subjects (p < 0.001;
PPV, 75%) and in 91 of 166 (55%) subjects with AKI by AKIN criteria (p = 0.002; PPV, 60%). By
multivariable logistic regression (age, gender, race, comorbidities, hemodynamic status, etc.), de novo
DP at time of admission independently predicted AKI (odds ratio [OR] 2.3, 95% confidence interval [CI]
1.4 -3.8, p = 0.001).
Conclusion: De novo DP represents a simple, inexpensive biomarker in sepsis with predictive power for
AKI. Further studies are required to fully elucidate the significance of new onset DP in AKI.
82

MICHIGAN POSTER FINALIST - RESEARCH Hussein Othman, MD
Lack of Value of Routine Transesophageal Echocardiography (TEE) in the Management of
Cardiovascular Implantable Electrophysiologicdevice (CIED)Infections
Hussein Othman, MD Joel Fishbain, MD Hanady Daas, MD Michael Tucciarone, MD Susan Szpunar PhD
Leonard Johnson, MD
Introduction: Introduction: A transesophageal echocardiography (TEE) is recommended in the
diagnostic evaluation of patients with proven or suspected (cardiovascular implantable
electrophysiologic device) CIED infections. The impact of TEE results on management and outcome in
CIED infections is unclear.
Methods: We performed a retrospective study of hospitalized patients with CIED infections at our
institution between 2000 and 2009. Data collected included: demographics, device specific information
(pocket versus lead-associated endocarditis (LAE), microbiology, TEE results (abnormal defined as lead
or valve vegetation) and outcomes (device removal, discharge or death due to CIED infection). Patients
with LAE were identified by positive lead cultures and/or blood cultures in the absence of pocket
infection. Patients with pocket infections were identified by documentation of local evidence of
infection. Outcomes (lead extraction rates, mortality, and duration of antibiotics) were compared in
patients who had a TEE performed or not using x2 and ANOVA. A p < or = 0.05 was considered
significant.
Results: 91 patients were included in the study (39 LAE and 52 pocket infections). The two study groups
were comparable in terms of mean age and gender distribution. Patients with LAE were more likely than
those with pocket infections to have a TEE (77% vs. 15%, p

MICHIGAN POSTER FINALIST - RESEARCH Anuradha Poolla, MD, MPH
Combination of 5FU and Difluorinated Curcumin is a Promising Therapeutic Strategy to Target Gastric
Cancer Stem Cells
Anuradha Poolla, MD., MPH., Shailendar S. Kanwar, Ph.D., Adhip P.N. Majumdar Ph.D., DSc.
Introduction: Despite advances in medicine, mortality from gastric cancer, the second leading cause of
cancer deaths world wide, remains unacceptably high. Current therapeutic regimen consisting of 5
Fluorouracil (5FU) or 5FU + Oxaliplatin (Folfox), the mainstay of gastrointestinal cancer therapeutics,
shows only a limited success that results in 40-60% recurrence. Although the reasons for this high
recurrence are not fully understood, one possible reason could be the presence of cancer stem cells
(CSCs) which are highly chemo-resistant and possess the limitless capacity to regenerate/proliferate. We
have recently demonstrated that the combination of Curcumin or its novel analog Diflurinated Curcumin
(CDF) with Folfox is highly effective in eliminating/ reducing colon CSCs. To determine whether a similar
therapeutic regimen would also be effective in eliminating gastric CSCs, the present investigation was
undertaken.
Methods: We examined the effects of 5FU and CDF, each alone, and the combination of both on the
growth of gastric cancer cells and expression of gastric CSC markers (CD-44, CD-166, ABCG-2, ALDH-
1). AGS, a gastric cancer cell line, originally derived from gastric adenocarcinoma was used.
Results: We observed that, although 5FU (6µM) caused about 40% reduction in cellular growth, it
produced a staggering 100-200% induction in CD-166 and ALDH-1 expression. However, when we
combined 5FU with CDF, we observed a marked 70% reduction in cellular growth, accompanied by a
significant 20-40% inhibition of CD-166 and ALDH-1 expression, indicating reduction in CSC population.
No apparent change in the expression of either CD-44 or ABCG-2 was observed with either of the
treatment.
Conclusion: In conclusion, our data suggests that the combination of 5FU and CDF could be a promising
therapeutic strategy to target the gastric CSCs which might lead to improved survival/delayed
recurrence.
84

MICHIGAN POSTER FINALIST - RESEARCH Vidushi Sharma, MD
Clinical Quality Assurance Project to Prevent Further Spread of Multi-drug Resistant Pseudomonas in
Patients Admitted to Intensive Care Unit.
Vidushi Sharma, MD, Simren Singh, MS3, Christine Rohr, DO, Suhasini Gudipati, MD, FACP, FIDSA.
Introduction: Infection control and hospital epidemiology are analagous to public health practices
directed at health care settings. Prophylactic measures in health care delivery settings have become
essential to precluding nosocomial infections; the spread of multi-drug resistant pseudomonas
in Intensive Care Unit (ICU) setting can be contained with consistent use of preventative methods.
Methods: This is a clinical quality assurance project to reduce clustering of multi-drug resistant
pseudomonas in neuro ICU. There was serial case reporting of MDR pseudomonas in about 10 patients
during the same time period. A committee was established to find out the possible environmental
factors contributing the spread of MDR pseudomonas. It was found that the shallow sinks(culture
positive for mdr pseudomonas) which can lead to back-splash while washing hands, ineffective
disinfectant used to kill MDRO, lack of cleaning of high touch areas, inability to store aerosol treatment
reservoirs dry, and lack of countertop space to place patient care items. After finding possible culprits
for the spread, a follow up was made with the RNs and EVs. All the NICU rooms were physically looked
at and a retrospective investigation was made at all the positive MDRO in last three months in lieu of
room placement, respiratory treatments, and same RN care providers. After collaborating all the
confounders, certain changes were implemented. The ICU rooms, which had shallow sinks (

MINNESOTA POSTER FINALIST - RESEARCH Ben Y Zhang, MD
Chapter Winning Abstract
Ben Zhang, Roxana Dronca, Phillip Young, Joseph Maalouf
Introduction: There were approximately 58,000 new cases of renal cell carcinoma in the U.S. last year,
85% of which were clear cell renal cell carcinoma (ccRCC). Cardiac metastasis from renal cell carcinoma
in the absence of vena cava extension is an exceedingly rare entity. It has been postulated that RCCs
have two distinct routes of spread leading to different presentations and outcomes.
Methods: We present two cases of ventricular metastases from renal cell carcinoma without vena cava
or right atrial involvement. We treated these two patients with sunitinib, a tyrosine kinase inhibitor,
and followed their subsequent clinical courses with routine office visits as well as serial echocardiograms
and cardiac MRIs.
Results: The first case involves an initially isolated inoperable metastasis to the left ventricle, which was
treated with systemic targeted therapy with favorable local response shown by serial MRIs. Our second
case illustrates a patient with an isolated metastasis in the interventricular septum with extension into
the right ventricle, which has also remained stable in size on sunitinib. No significant drug toxicity has
been demonstrated in either case.
Conclusion: We describe our management of these two cases and discuss the current medical and
surgical approaches to the treatment of cardiac metastases from renal cell carcinoma. Currently,
combination therapy that includes surgical debulking and systemic treatment affords the best chance of
palliation. For patients whose tumors prove to be inoperable, based on the findings in our two cases,
we propose that targeted therapy with tyrosine kinase inhitors is a viable and safe therapeutic
alternative to metastasectomy.
86

MINNESOTA POSTER FINALIST - RESEARCH Kristina Krohn, MD
Improving Steroid use in COPD Exacerbations
Kristina Krohn, MD, Lauren Haveman, MD, Brian Harahan, MD, PhD, Sheila Nguyen, Md, Emily
Schafhauser, MD, Brian Hanson, MD, Elizabeth Hofbauer, MD, Benji Mathews, MD, Gregory Poduska,
MD, Hope Pogemiller, MD, Saba Beg, MD, and Paula Skarda, MD
Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of hospitalizations and
mortality in the United States. Exacerbations of COPD are best treated with corticosteroids and by
addressing the underlying cause of decompensation. In practice, the dose and route of steroid
administration in COPD exacerbations varies widely.
Methods: We performed a literature review to identify the effectiveness of various steroid doses and
administration routes used in the treatment of COPD exacerbations. We then examined the current
steroid administration practices used for all patients admitted to Regions Hospital in St. Paul, Minnesota,
with a primary diagnosis of COPD exacerbation between January 2010 and December 2010.
Results: A review of the literature identified five key studies of steroid use in COPD exacerbations. The
earliest of these studies demonstrated the benefits of using methylprednisolone 125 mg IV vs. placebo.
Side effects related to this dose included hyperglycemia and upper GI bleeding. Subsequent studies have
compared lower oral doses (20 to 80mg prednisone equivalent) to high IV doses and found low-dose
oral steroids to be equally effective with fewer side effects. Among patients admitted for COPD
exacerbation at Regions Hospital in Saint Paul, Minnesota (n=225), 39% received low-dose (20 to 80 mg
prednisone equivalent) oral prednisone in the emergency department. Twenty-two percent received
higher doses or IV doses in the emergency department. The initial inpatient steroid dose of these same
patients revealed that 66% versus 33% received low-dose compared to high-dose or IV steroids,
respectively. Overall 42% of patients received IV or high dose steroids in the emergency department, for
their initial inpatient dose of steroids or both. There was no correlation (P

MINNESOTA POSTER FINALIST - RESEARCH Evan L Hardegree, MD
Novel Measures of Biventricular Dysfunction are Better Predictors of Outcomes in Pulmonary
Hypertension
Evan L. Hardegree, MD, Arun Sachdev, MD, Hector R. Villarraga, MD, Robert P. Frantz, MD, Michael D.
McGoon, MD, Robert B. McCully, MD, Jae K. Oh, MD, Patricia A. Pellikka, MD, Garvan C. Kane, MD,
Introduction: Pulmonary arterial hypertension (PAH) is a devastating condition characterized by
pulmonary vascular remodeling and right heart failure. Outcome is determined by right heart
adaptation, but conventional echocardiographic measures are limited due to complex right ventricular
geometry and translational motion. Speckle-tracking echocardiography is a novel angle-independent
technology used to assess myocardial strain (a sensitive measure of ventricular function). Furthermore,
the right (RV) and left ventricles (LV) share a common pericardial sac and septum. Hence it is plausible
that in PAH, where the RV but not LV faces a marked increase in afterload, a dysfunctional RV may
impart abnormalities on LV function through ventricular interdependence. We sought to correlate RV
and LV strain patterns with clinical outcomes in PAH.
Methods: Hemodynamic catheterization and 2D, Doppler and speckle tracking strain transthoracic
echocardiography were performed in 82 consecutive adults with PAH. Cox proportional hazards
regression models were used to identify correlates of mortality. Survival was assessed over two years.
Results: Patients had catheter-confirmed PAH (mean PA pressure 49 ± 10 mm Hg; normal -25%). LV
free wall longitudinal systolic strain was concomitantly reduced at -15±3% (normal > -18%) despite
apparently normal LV systolic function (LVEF 65 ± 8%). A delayed relaxation mitral inflow pattern
predicted worse outcome (2-year survival 45% [95% CI 26-66] versus 83% [71-91], p

MISSISSIPPI POSTER FINALIST - RESEARCH Sushant Khaire, MBBS
Microalbuminuria is Related to Endothelial Health in African Americans
Sushant Khaire, MD Other Authors: Solomon Musani PhD, Eric McClendon PhD, Herman Taylor MD.
Senior Author: Ervin Fox MD
Introduction: Microalbuminura independently predicts cardiovascular disease risk; endothelial function
may provide a potential biological mechanism to explain this association. There is evidence in
predominantly non-Hispanic white populations that microalbuminuria is related to endothelial
dysfunction by flow mediated dilation of the brachial artery. Less is known on the relation between
endothelial dysfunction to the presence of microalbuminuria in African Americans.
Methods: Between 2007 and 2010 digital arterial tonometry was performed on a subset of participants
of the Jackson Heart Study using the endoPAT2000. Baseline pulse wave amplitude (BPA) as a measure
of endothelial tone and reactive hyperemic index (F-RHI) as a measure of endothelial function were
determined using the device. For this study, microalbuminuria was defined as a urinary albumin:
creatinine ratio = 17mg/g in men and = 25 mg/g in women. We compared the differences in least
square means adjusted for age and sex, and adjusted for multiple traditional clinical covariates using a
generalized linear model.
Results: There were 834 participants in the study population (mean age 58.5 years, 61% women), 108
(13.0%) had microalbuminuria. In the multivariable adusted analysis, BPA was significantly (P=0.036)
associated with microalbuminuria in men and F-RHI was weakly significantly (P=0.08) associated with
microalbuminuria in women.
Conclusion: We found using digital arterial tonometry a significant relation between endothelial tone
and microalbuminuria in men and between endothelial dysfunction and microalbuminuria in
women. These findings support the theory that microalbuminuria is an early marker of vascular disease
and may help to explain the link between the presence of microalbuminuria and the development of
cardiovascular atherosclerotic disease in diabetics.
89

MISSISSIPPI POSTER FINALIST - RESEARCH Arnaldo Lopez-Ruiz, MD
Angiotensin 1-7 Protects against Renal Ischemia Reperfusion Induced Acute Kidney Injury and its
Associated Cardiac Dysfunction
Arnaldo Lopez-Ruiz Andrea Soljancic Kiran Chandrashekar Ruisheng Liu Luis A. Juncos
Introduction: Acute kidney injury induces inflammatory changes which can lead to acute cardiac
dysfunction (type 3 cardiorenal syndrome). Angiotensin-(1-7) (Ang 1-7) is a clinically relevant Ang
subtype that exerts cytoprotection through its cardiovascular and baroreflex actions which counteract
those of Ang II on the renin-angiotensin system.. We hypothesized that exogenous infusion of Ang1-7
protects against Ischemia/reperfusion (I/R) induced AKI and its subsequent cardiac sequelae.
Methods: Male SD rats (n=6/group) were randomized into 4 groups, 1) Sham, 2) AKI, 3) AKI+Ang1-7, 4)
AKI+ Ang1-7+ A779 (Ang 1-7 antagonist). AKI was induced by I/R, through bilateral renal pedicle
clamping for 40mins. Ang1-7 and its antagonist were given daily at 574 µg/kg or 1148 µg/kg i.p
respectively, starting 1 hr before I/R and continuing for 3 days after the renal insult. During follow up,
plasma creatinine and urinary NGAL (renal injury marker) were measured. The rats were sacrificed and
the kidneys and hearts collected to estimate inflammation (TNFa), cardiac stress (BNP) and VEGF (which
may have cytoprotective effects).
Results: We noted that AKI is associated with reduced levels of Ang 1-7 in the kidneys (1.3±0.2 vs.
3.9±0.3 ng/ml) and the heart (1.7±0.1 vs. 2.9±0.2 ng/ml) compared to shams. AKI also increased cardiac
tissue levels of BNP (4.8±0.4 vs. 0.3 ± 0.05ng/ml) and renal and cardiac TNFa expression (86±5 vs.
4.8±0.7 and 54±6 vs. 4.1 ±0.7pg/ml respectively) compared to sham. However, rats with AKI that were
given an exogenous infusion of Ang1-7 had lower renal dysfunction (plasma creatinine decreased from
2.5±0.2 to 1.6±0.15 mg/dl) and injury (NGAL decreased from1340±132 to 615±84UI/ml) compared to
shams. Additionally exogenous Ang1-7 infusion also attenuated renal and cardiac TNFa expression (86±5
vs. 36.2±4.2 and 54±6 vs. 28.7±7.5 pg/ml respectively), and blunted cardiac BNP (4.8±0.4 to 2.8±0.3
ng/ml). Moreover, exogenous Ang1-7 ameliorated AKI-induced decrease in renal and cardiac VEGF
expression (from 97.4±10 to 198± 21 and 174±23 to 276±21 pg/ml respectively). These beneficial effects
of Ang 1-7 were abolished by administration of its antagonist.
Conclusion: Hence renal I/R-AKI contributes to cardiac dysfunction and is associated with inflammation
and injury and exogenous Ang 1-7 confers protection against I/R- AKI, perhaps by enhancing levels of
potential cytoprotectants, including VEGF.
90

MISSISSIPPI POSTER FINALIST - RESEARCH Dominique J Pepper, MD
Tuberculosis Mortality in a High HIV Prevalent Setting
Dominique J Pepper, MD Co-authors: Feriyl Bhaijee, MD, Wanmei Wang, Imran Sunesara, Suzaan
Marais, MD, Robert J. Wilkinson, MD, Virginia de Azevedo, MD, Gary Maartens, MD.
Introduction: Tuberculosis (TB) is the leading infectious cause of death worldwide, especially among
those infected with HIV. One strategy to reduce TB-related mortality is to identify and target groups of
TB patients that are at increased risk of death. We undertook to determine relationships between TBrelated
mortality and age, gender, and HIV status.
Methods: We analyzed a surveillance population of 12,045 TB patients who were organized by gender,
HIV status, and degree of immune suppression into the following groups: HIV uninfected (Male/Female:
2,409/1,525), HIV-infected with a CD4 count > 350 cells/microL (M/F: 1,665/2,253), and HIV-infected
with a CD4 count < 350 cells/microL (M/F: 1,901/2,292). For each group, we calculated age-specific TB
mortality proportions, determined adjusted odds ratios (aOR) for death, and performed logistic
regression analysis. We also created Cox-Proportional hazard models to determine hazard ratios (HR) for
death.
Results: We found a previously unexplored curvilinear relationship between TB-related mortality and
age, gender, and HIV status: increasing age (HR=1.6, 95%CI: 1.51-1.76) and advancing degree of
immune-suppression (HR=1.5, 95%CI: 1.33-1.64) were significantly associated with an increasing hazard
of death, while gender was not (HR=1.0, 95%CI: 0.84-1.22). All HIV-infected patients of 15 years age or
older were at increased risk of death (aOR=2.3, 95%CI: 1.95 – 2.79). Among TB patients of 55 years age
or older, HIV-infected women were more likely to die than HIV-infected men (aOR=3.7, 95%CI: 1.83 –
7.34), while HIV uninfected men were more likely to die than HIV uninfected women (OR=1.9, 95%CI:
1.01 – 3.43).
Conclusion: Novel features of this work are the curvilinear relationships between TB-related mortality
and age, gender, and HIV status. Furthermore, these data add impetus to current WHO and CDC
guidelines that antiretroviral treatment be initiated among all HIV-infected adults with active TB disease,
irrespective of CD4 cell count. Among TB patients of 55 years age or older, interventions should be
prioritized in HIV-infected women and HIV uninfected men.
91

MISSISSIPPI POSTER FINALIST - RESEARCH Licy L. Yanes Cardozo, MD
Angiotensin II Stimulate TNF-Alpha in a Hyperandrogenic Female Rat
Licy L. Yanes Cardozo, MD, Damian G. Romero, PhD and Jane F. Reckelhoff, PhD
Introduction: Hyperandrogenic conditions in women such as polycystic ovary syndrome (PCOS) and
postmenopause are associated with high risk of cardiovascular diseases. However the precise
mechanisms by which increases in androgens promote cardiovascular disease in women are unknown.
We have recently reported that androgen administration to female Sprague Dawley rats, beginning at 4
wks of age (prepubertal), increases blood pressure (BP), inflammatory cytokines levels such as Tumor
Necrosis Factor-alpha (TNF-a), food intake, fat deposits, and plasma leptin and insulin. Androgens
increase Ang II levels in several hypertensive animal models. In the present study, we tested the
hypothesis that activation of intrarenal renin-angiotensin system (RAS) increases blood pressure and
inflammatory cytokines in the hyperandrogenic female (HAF) rats.
Methods: Dihydrotestosterone (DHT) pellets (7.5 mg/90 days, sc, HAF rats) or placebo pellets, were
implanted in female Sprague Dawley rats (n=10) at 4 weeks of age. After 1 mos of DHT treatment,
enalapril (250 mg/l, drinking water) was administered for 2 mos. Mean arterial pressure (MAP) was
measured by radiotelemetry for the last 2 weeks of treatment and kidneys were harvested for
determination of TNF-a levels by ELISA.
Results: HAF had higher MAP compared to placebo animals (108±2 vs. 96±1 mm Hg, p

MISSOURI POSTER FINALIST - RESEARCH Delene P Etwaru, MD
Quality Improvement of ANCA Testing Process at MU - A 12 Month Data Review
Delene Musielak, MD; Emily Larson, DO; Chokkalingam Siva, MD, MS; Menka Desai, MD; Darcy
Folzenlogen, MD Division of Rheumatology, Department of Internal Medicine
Introduction: Anti Neutrophil Cytoplasmic Antibodies (ANCA) are useful to diagnose certain vasculitides,
but are often nonspecific. Guidelines and gating policies have been proposed to discourage
inappropriate use which can lead to erroneous diagnoses and improper treatments.
Case example: A 61-year-old female was transferred to the University Hospital after prolonged
hospitalization elsewhere. She had been admitted earlier for septic arthritis in the wrist and developed
deep venous thrombosis and pulmonary embolism in the hospital. Random serological testing lead to a
positive P-ANCA result and a diagnosis of “P-ANCA vasculitis” without further evidence. High dose
steroids for several weeks lead to multiple intra-peritoneal and soft tissue abscesses and osteomyelitis.
The patient became disabled from the iatrogenic complications of prolonged steroid use. She does not
have evidence of vasculitis three years post discharge.
Methods: A database with all consecutive ANCA requests at MU has been established beginning June 1 st
2009. Medical records on requests for the first 12 months were reviewed for testing indications (table1).
The data was analyzed to review whether the requests met the 1999 ANCA testing guidelines.
Results: Only 27% of ANCA tests were ordered according to the guidelines since 417/570 (73%) of
requests did not meet the 12 testing criteria. The top most common reasons tests were ordered outside
of criteria were hepatitis/cirrhosis (36%), other non-specific symptoms (18%) and hemochromatosis
(0.6%).
Conclusion: 73% of requests did not meet testing criteria, and per guidelines are deemed inappropriate.
For quality improvement, data will be monitored and the information will be shared with the requesting
physicians. Additional research regarding education of providers requesting tests and diagnosis
outcomes of those in whom the test was ordered is underway.
93

MISSOURI POSTER FINALIST - RESEARCH Mayank K Mittal, MD
Inhibition of Vascular Smooth Muscle Cell Migration by a Novel Tiplaxtinin Eluting Stent
Mayank K Mittal,Tammy Strawn, William P Fay
Introduction: Plasminogen activator inhibitor-1 (PAI-1), a key regulator of the plasminogen activator
(PA) system and fibrinolysis, also regulates vascular remodeling. Elevated levels of PAI-1 are associated
with the development of intimal hyperplasia. The purpose of this study was to develop and characterize
intravascular stents capable of eluting a pharmacological inhibitor of PAI-1, tiplaxtinin.
Methods: Tiplaxtinin was coated on bare metal stents with a spray apparatus using polylactic-co-glycolic
acid as the binding polymer. Scanning electron microscopy revealed uniform stent coating. HPLC
analysis of aqueous eluates of tiplaxtinin-coated stents revealed sustained elution of tiplaxtinin from
stents for up to 21 days. To determine if tiplaxtinin eluting from stents retained activity and inhibited
smooth muscle cell migration, tiplaxtinin- and vehicle-control-coated stents were placed in transwell cell
migration apparati along with human coronary artery SMC. PDGF-BB-induced cell migration was
measured.
Results: Tiplaxtinin-coated stents inhibited SMC migration by 89.1 ± 10.2 % compared to control (p

NEBRASKA POSTER FINALIST - RESEARCH Swati Prasad, MBBS
Vitamin D Deficiency and Statin Associated Myopathy: A Systematic Review
Prasad, Swati Kominneni, Vijaya Sontineni, Siva Hurley, John
Introduction: Statin therapy is frequently used for atherosclerotic disease prevention and myopathy
associated with it prevents the optimal use of these agents. Vitamin D deficiency has emerged as a
factor in statin associated myopathy and the therapeutic role of vitamin D supplementation to improve
statin tolerance is unclear. Our objective is to study the impact of vitamin D deficiency and
supplementation on statin induced myalgia.
Methods:A retrospective analysis of all published studies in the English language literature that have
reported on vitamin D deficiency and myalgias associated with statin therapy was conducted. An Online
search of Pub Med database and Google Scholar results using the following search terms - “statins,
vitamin D deficiency, 25 (OH) vitamin D, vitamin D supplementation, myalgias, statin induced myopathy,
statin associated myopathy”. Studies with subjects on statin therapy, a measured vitamin D level and
reported frequency of symptomatic myalgia or myopathy were included for the analysis. Studies with
subjects having myalgia due to identifiable causes including steroid therapy, hypo/hyperthyroidism,
fibromyalgia, electrolyte abnormalities, and/or prior vitamin D supplementation were excluded from
analysis.
Results: A total of 2177 articles were retrieved, after initial review six studies were considered relevant
and addressed Vitamin D deficiency among patients on statin therapy. Of the six relevant studies, a total
of 10801 subjects were on statin therapy for treatment of hyperlipidemia. Mean age of total study
patients were 59.6+5.1 years and male to female ratio was 2.5. Among the total subjects, 2309 patients
had a measured serum Vitamin D level and were included for pooled analysis. Vitamin D deficiency
(defined as < 32ng/ml for this study) was present in 52% (n=1202) of patients. Myalgia was present in
16% (n=371) of the included subjects and 25% (n= 301) of the Vitamin D deficient subjects who were on
statin therapy. Vitamin D replacement therapy in average conventional doses of 50,000 units/week for
12 weeks was reported in 50% (n=153) of the Vitamin D deficient patients with myalgia resulting in
normalized levels. We found 81.5% (n=125) of the Vitamin D replaced subjects became statin tolerant
upon re-institution of same or different statin.
Conclusion: We conclude that Vitamin D deficiency is a significant factor underlying myalgia among
statin intolerant patients. Vitamin D replacement improves myalgia in such patients along with
improving tolerance to statins for the treatment of hyperlipidemia and subsequent prevention of
atherosclerotic disease.
95

NEBRASKA POSTER FINALIST - RESEARCH Subhankar Chakraborty, MD
Antiproliferative, Antiinvasive and Chemosensitizing Effects of Holy Basil leaf extracts in Human
Pancreatic Cancer Cells Suggests its Potential Utility as a Source for Novel Anticancer Compounds
Subhankar Chakraborty, MD Tomohiro Shimizu, MD, Maria Torres-Gonzalez Ph.D.,Joshua Souchek
M.S.,Satyanarayana Rachagani Ph.D., Muzafar Macha Ph.D., Apar Kishor Ganti MD, Erik D Moore
M.S.,Surinder K Batra Ph.D.
Introduction: Pancreatic cancer (PC) therapy is currently limited by intrinsic resistance of cancer cells to
available chemotherapeutics. This has fuelled research into alternative therapies, particularly
phytochemicals. Ocimum sanctum (or “Holy basil”), a medicinal herb found in semitropical and tropical
parts of India, has been used for thousands of years in traditional medicine to treat diverse ailments.
However, its effect on cancer cells remains largely unknown. The objective of our study was to
investigate whether ethanolic extracts of O.sanctum leaves (EEOL) or the essential oil of O.sanctum
leaves (EOOS) could inhibit aggressiveness of PC cells in vitro and alter their sensitivity to existing
chemotherapeutics.
Methods: Dried basil leaves were purchased from four different vendors (New Chapter Inc (NC),
Superior Herbs (SH), ClubNatural (CN) and Morpheme (Morph)) and EOOS from Now Foods
(Bloomingdale, IL). PC cells (ASPC-1, MiaPaca, Capan-1 and HPAF/CD18) grown under standard culture
conditions were treated with either EEOL or EOOS diluted in culture medium. The optimum dose for in
vitro studies was determined from a combination of the IC-50 values, in vitro effects on clonogenecity
and growth kinetics and ability to downregulate MUC4 expression in vitro (in Capan-1 and HPAF/CD18
PC cells). MUC4, a membrane bound glycoprotein has been demonstrated to promote survival,
metastasis and chemoresistance in PC cells and hence was used as a surrogate marker of O.sanctum’s
anti-PC effect. In vitro assays for migration, invasion, cell cycle, apoptosis and chemosensitivity were
carried out.
Results: EEOL of NC was the most effective (IC50 range- 0.7-127 µg/ml) and that of CN the least effective
(IC50 range- 74-2,086 µg/ml) in inhibiting proliferation of PC cells in vitro. IC-50 for EOOS ranged from
5X10 -4 to 0.17 %v/v. The optimum concentration of EEOL and EOOS that inhibited PC cell growth were
determined to be 80µg/ml and 0.1% v/v respectively. EOOS/EEOL significantly inhibited cell cycle
progression, induced apoptosis (EEOL>EOOS) and inhibited migration and invasion in PC cells. Pretreatment
with EEOL/EOOS significantly increased the sensitivity of PC cells to Cisplatin, Docetaxel and
Herceptin while a combination of EEOL/EOOS and chemotherapeutics was more effective than the
individual drugs alone. EEOL/EOOS also significantly downregulated the expression of genes that
regulate proliferation, migration and invasion including MUC4, activated ERK-1/2, FAK, p65 (subunit of
NF-kB) and N-cadherin.
Conclusion: EEOL/EOOS have potent anti-proliferative, anti-motility, anti-invasive and chemosensitizing
effects on PC cells. Our results suggest that O.sanctum leaves could be a novel source of antineoplastic
compounds for therapy of PC.
96

NEW JERSEY POSTER FINALIST - RESEARCH Hao Zhang, MD
The Study of Bone Remodeling Activity in a Mouse Model of Osteogenesis Imperfecta
Zhang, Hao, MD, PhD Pleshko, Nancy, PhD Jaffe, Eric, MD.
Introduction: The goal of the current study is to investigate bone remodeling of Osteogenesis
Imperfecta (OI) in an in vitro calvaria-Osteoclast (OC) co-culture system from wild type and OI (oim/oim)
mice, a model of moderate-to-severe OI.
Methods: Calvarias and bone marrow cells were harvested from 4-8 week old wild type and oim/oim
mice. Calvarias and bone marrow cells were cultured in a-MEM containing 10% FBS in the presence of
10 -8 M 1, 25-(OH)2D3 and 10 -6 M prostaglandine E2 at 37 0 C for 14 days. The OBs from the calvaria
migrated and spread into the culture plate, supporting the differentiation of OCs on the surface of both
culture plate and calvaria. Two groups were examined: 1) wild type calvaria cultured with wild type OCs;
2) oim/oim calvaria cultured with oim/oim OCs. After 14 days, calvarias were scanned by SEM to assess
resorption pits. Culture plates with OCs and OBs attached were TRAP-stained to identify OCs and ALPstained
to identify OBs. Ratio of OC/OB was calculated. RNA from each sample was reverse transcribed,
and levels of RANKL and OPG gene expression were quantified by real time PCR and were detected on a
MyiQ Single Color Real Time PCR detection system.
Results: At day 14, there were significantly fewer number of OCs from the oim/oim group compared to
the wild type group (92.50+23.18/mm 2 vs 379.00+ 136.53/mm 2 , p

NEW JERSEY POSTER FINALIST - RESEARCH Sreelatha Naik, MD
Promoting Empathy and Understanding of Poverty Among Medical Students and Residents Through
the Use of a ‘Poverty Simulation’
Sreelatha Naik, MD Neil Kothari MD, Sophia Chen DO
Introduction: Most future physicians enter medicine professing a desire to help those in need. During
the course of medical training, however, physicians-in-training can become detached from their initial
idealism. This decrease in empathy has been attributed to an emphasis on objectivity and potential
development of ‘elitism.’ In addition, students from affluent backgrounds may find it difficult to
understand the hardships faced by patients living in poverty. Although 14.3% of Americans live in
poverty, approximately 60% of medical students are from the upper quintile of income. Positive patient
perceptions of physician empathy improve information exchange and trust, which improve patient
satisfaction and compliance. Therefore, enhancing trainees’ ability to empathize with patients may
improve clinical outcomes.
Methods: An interactive Poverty Simulation (developed by the Missouri Association for Community
Action) was implemented for Internal Medicine residents and second-year students at UMDNJ – New
Jersey Medical School, in which participants experience some of the stressors faced by those living in
poverty. The objectives were to describe the influence of societal factors on poverty, to become aware
of the barriers faced, and to exhibit greater sensitivity to the realities of living in poverty.
72 residents and students were randomized into families of four members each. They received packets
including family profile and resources. Trainees assumed the identity of family members and roleplayed
over several hours. Participants also completed optional pre- and post-surveys, which contained
16 items that addressed participants’ perceptions about poverty. 62 (86%) completed at least one of
the surveys. Faculty then led discussions with participants about how their attitudes changed due to the
simulation.
Results: Three items demonstrated statistically significant differences, while two others trended
toward significance.
25.8% of participants believed that the poor get “a lot of breaks” with respect to expenses such
98
as rent and utilities vs. only 10.2% post-simulation (p=0.026).
66.1% felt that poor people could improve their situation if they applied themselves vs. 41.7%
post (p=0.007).
41.9% felt that the poor “spend too much money on fast food” vs. 23.3% post-simulation
(p=0.029).
52.5% felt that poor people in this country “have it great compared to poor people in other
countries” vs. 38.3% post (p=0.119). 62.3% felt that the community provided effective services
to families vs. 48.3% post-simulation (p=0.122).

Conclusion: The data suggests that this half-day simulation significantly increased the understanding of
poverty in our medical students and residents. However, the data is limited due to the small size of this
pilot study. In addition, although the survey assessed understanding of poverty, future studies using a
validated measure of empathy, such as the Jefferson Scale of Physician Empathy, need to establish
whether an increased awareness of poverty leads to improved empathy.
99

NEW JERSEY POSTER FINALIST - RESEARCH jennifer c kam, md
Utility of CT Scan Evaluation for Predicting Pulmonary Hypertension in Patients with Right-Sided
Cardiac Catheterization
Kam, J.C.*, Pi, J., Riar, S., Elnahar, Y., DeBari, V., Klukowicz, A.J., Shamoon, F. and Miller, R.A.
Introduction: Right heart catheterization is currently the gold standard used to detect pulmonary
hypertension (PH) and to grade its severity. However, cardiac catheterization, like any invasive
procedure, is associated with important risks and complications. Computerized topography (CT)
scanning of the chest is a non-invasive investigative modality commonly used in the diagnosis and
management of patients with pulmonary pathology. The purpose of our study is to determine the utility
of CT scans for detecting PH in patients who have had right heart catheterization by comparing CTmeasured
main pulmonary artery diameters (MPAD) to right-heart catheterization-determined mean
pulmonary artery pressures (PAP).
Methods: A retrospective review was conducted on 40 patients with left-sided cardiac pathology who
had undergone both right-heart catheterization and CT scanning of the chest at St. Michael’s Medical
Centre in Newark, NJ. Patients with catheterized-measured pulmonary artery pressures (PAP) between
25-40mmHg and >40mmHg were identified as having mild-moderate and severe pulmonary
hypertension respectively. Mean pulmonary artery diameter (MPAD) was measured on CT scans at the
widest portion of the main pulmonary artery within 3mm of the bifurcation. Statistical analyses were
performed using one-way ANOVA followed by Tukey’s test for multiple comparisons and significant
differences were accepted at p

NEW JERSEY POSTER FINALIST - RESEARCH Mujtaba Hasnain, MD
Assessment of Proper Sharps Disposal Among Patients with Diabetes Mellitus
Mujtaba Hasnain, md, Jennifer Costello pharmd, Nurlela Gouveia md, Ashish Parikh, md
Department of medicine, saint barnabas medical center, livingston nj
Background: A great deal of attention is given to proper sharps disposal in both the clinical and hospital
settings, as occupational exposure to blood borne pathogens from accidental injuries is of serious
concern. Patient education is necessary to ensure proper sharps disposal in the home environment, in
order to prevent unnecessary injury and exposure to contaminated blood products
Objective: Phase one of this three part study was designed to evaluate the level of education that
diabetic patients receive regarding proper disposal of sharps (needles, lancets) from their prescribing
providers and/or dispensing pharmacists. Phase two evaluated the effect of patient education of proper
sharps disposal at home.
Methods: An anonymous survey assessing sharps disposal knowledge was administered to all diabetic
patients presenting to the Internal Medicine Faculty Practice from April to June of 2010 (phase 1).
Following completion of the survey, patients were educated regarding proper disposal of their used
diabetic supplies by a clinical pharmacist. Phase 2 of the study, conducted between October and
December of 2010, re-evaluated proper diabetic sharps disposal following initial education by redistributing
anonymous surveys to all patients. To aid in proper disposal, our practice implemented a
free disposal system for all patients to utilize. Phase 3 of the study, in which area practitioners are being
surveyed regarding provision of patient education, is currently underway. In addition, educational
materials highlighting safe disposal practices are being mailed to all the patients in our practice.
Results: A total of 44 surveys were completed in phase 1 of the study. Only 16% of patients stated that
they were educated regarding proper diabetic disposal by a healthcare worker, while overwhelming
majority (84%) of patients reported being unaware that proper sharps disposal was necessary. Eighty-six
percent of patients reported improper disposal of diabetic supplies in the regular trash. A total of 25
surveys were completed in phase 2 of the study; of these, 17 patients had also completed the initial
survey in phase 1. All 17 patients (100%) adhered to proper disposal of techniques after receipt of
education. Eighty –four percent of patients utilized the free sharps disposal system provided by our
office.
Conclusion: Diabetic patients are under-educated regarding safe sharps disposal practices. Patient
education can positively impact and improve safe needle disposal practices in the community. Providers
should be encouraged to discuss proper sharps disposal at home with their patients.
101

NEW JERSEY POSTER FINALIST - RESEARCH Hari Om Sharma, MD
The Use of Orthostasis as an Indicator of Volume Status in Heart Failure and its Role in Comparison to
BNP
T.E Waggoner D.O, Hari Om Sharma MD, Rajiv Tayal M.D J E Malinowski PhD, S M Abo D.O.
Introduction: Intro Congestive Heart failure (CHF) is the most common diagnosis for hospitalizations
and the leading reason for readmissions among Medicare patients. The U.S. Healthcare system
continues to be financially taxed regarding diagnostic and therapeutic measures in the managing of
decompensated CHF. We determined whether the bedside evaluation of orthostatic hypotension has
utility in being an inexpensive, easily measurable and accurate guide to the identification of a euvolemic
state in the treatment of decompensated CHF.
Methods: In this prospective pilot study, enrollment was over a six-month period from a single hospital
in northern New Jersey. Patients =18- years-old were included with decompensated CHF. Patients had to
be able to maintain supine or erect posture for the duration necessary to evaluate orthostatic changes.
Patients had to have plasma creatinine

NEW YORK POSTER FINALIST - RESEARCH Eric J Berkowitz, MD
The Clinical Implications of Trusting the Automated QTc
Eric J Berkowitz, MD; Georgia Panagopoulos, PhD; Robert Graham, MD
Introduction: Long QT syndrome is a genetic or acquired condition characterized by a prolonged QT
interval on the surface ECG and is associated with a high risk of sudden cardiac death due to ventricular
tachyarrhythmias. Inaccurate measurements can lead to the inappropriate use of medications that
would otherwise be avoided. Furthermore, the overwhelming majority of house staff rely on the
automated QTc when interpreting ECGs. Our objective was to assess the accuracy of the automated
QTc and to evaluate potential clinical implications.
Methods: We evaluated 142 ECGs obtained via MUSE network. 48 normal ECGs met our inclusion
criteria: sinus rhythm, HR440msec for males, >460msec for females. Statistical analysis was done
using the Kappa Coefficient to calculate the degree of agreement between the automated and manual
QTc values. In addition, information was obtained on medications ordered on the date of the ECG via
Lenox Hill Hospital Sunrise EMR software.
Results: There were 23 Males and 25 Females with a mean±SD age of 56±16 and mean HR±SD of 75±16.
We found 35.4% (17/48) of ECGs had an abnormal QTc via manual calculation. Of these 17 ECGs, 6 were
identified as normal via the automated software. Of these 6 patients, 4 had received orders for
medications with QT prolonging potential. 6.3%(3/48) of the ECGs were found to have a markedly
prolonged QTc value of >500msec and 2 of these 3 ECGs were not identified on the automated software.
In total, 5 of these 7 patients were given potentially dangerous medications. The Kappa value was found
to be 0.53 (P < 0.05).
Conclusion: We found a suboptimal degree of agreement between automated and manual QTc values,
which may have deleterious clinical implications, especially upon prescribing certain medications. Health
care practitioners ought to manually calculate the QTc as decisions on medications and other therapies
may be compromised.
103

NEW YORK POSTER FINALIST - RESEARCH Elena Katz, MD
A Successful PDSA: Improving Compliance With Platelet Transfusion Guidelines
Elena Katz, MD Malgorzata Klek MD, Randy Levine MD, Robert E.Graham MD. Lenox Hill Hospital, New
York, NY.
Introduction: Evidence-based guidelines are developed and promoted to help physicians implement
best practice care. The American Society of Hematology (ASH) platelet transfusion guidelines changed in
2007 to a prophylactic transfusion threshold of 10, 000/µL from the previous 20,000/µL. We conducted
a retrospective analysis to assess how well physicians are complying with the new professional
guidelines as well as the older, less stringent criteria to administer platelet transfusions. Subsequently,
we assessed the effect of an educational intervention on transfusion practices.
Methods: All patients receiving platelet transfusions over a five-month period from Jan-Feb, and April-
June 2010, admitted to the medical, critical care and cardiac services were reviewed. The medical record
clinical indication was then evaluated against the ASH 2007 “Evidence-Based Platelet Transfusion
Guidelines” (Slichter SJ. Hematology 2007): bleeding and platelets =50, 000/µL, pre-invasive procedure
and platelets =50, 000/µL, prophylactic transfusion for platelets =10, 000/µL and WHO bleeding grade =
2. We also assessed how the patients’ clinical indication met the previous prophylactic threshold for
platelet transfusion of =20, 000/µL.
Following initial data collection, we implemented an educational intervention by giving a lecture,
reviewing all indications for platelet transfusions, and distributing a pocket card to the house-staff on
the medical wards in August, 2010. We subsequently gathered post-intervention data following the
methods described above for four consecutive months from Sept-December, 2011. Data analysis was
conducted using a Z-test with a = 0.05 and Z critical value = 1.96.
Results: Eighty-six patients on the selected units received a total of 241 platelet transfusions preintervention
and 81 patients received a total of 237 platelet transfusions post-intervention. The
patient’s clinical indication met the old guidelines in 63% of cases pre-intervention and in 81% of cases
post-intervention with a significant p-value of

NEW YORK POSTER FINALIST - RESEARCH Jaxel Lopez Sepulveda, MD
Transtheoretical Model (TTM) Stages of Change Related to Diet & Physical Activity Behaviors Among
Inner City Minority with High Prevalence of Obesity
Jaxel Lopez Sepulveda, MD Juan Buitrago MD Otto Garay MD Teresa Giraldo MD Maria Ramos Carla
Boutin Foster MD Linda Gerber PhD Balavankatesh Kanna MD MPH1
Introduction: Obesity is a large public health problem in the United States (US). Lack of physical activity
(PA) and poor eating choices are major reasons. Nationwide, programs have attempted to tackle obesity
with limited success. According to TTM, health behavioral change occurs in progressive stages from precontemplation,
contemplation, preparation (TTM-ES), to action and maintenance (TTM-AM). This model
helps analyze the readiness of individuals to make healthy changes. This study describes a sample of
minority individuals with respect to their stage of change.
Methods: An anonymous survey was conducted in the South Bronx, New York city (NYC) to study the
association of TTM stages of PA and diet change to obesity. The survey assessed TTM stages, perception,
understanding of diet/ PA /weight, and willingness to act. BMI (kg/m 2 ) data were collected. Subjects
who were in TTM –AM stages of healthy diet behavior were compared to those who were in early stages
(TTM-ES). Using logistic regression, odds ratios (OR) & 95% confidence intervals (CI) were calculated. A p
value of < 0.05 was considered significant.
Results: Of the 800 surveyed, 580 (72.5%) had BMI > 25; 738(92.3%) were Latinos, 485 (60.7%) were
women; 371(46.3%) subjects were in TTM-AM and 359(44.9%) in TTM-ES of diet; 378(47.3%) subjects
were in TTM-AM and 388(48.5%) in TTM-ES of PA. Subjects in TTM-AM of diet were less likely to be
overweight/obese (OR 0.92, CI 0.89-0.95, p

NEW YORK POSTER FINALIST - RESEARCH Rakesh Malhotra, MD MPH
Clinical Risk Assessment Score for Acute Kidney Injury in Patients Admitted to Intensive Care Unit
Rakesh Malhotra, MD MPH Rakesh Malhotra, Etienne Macedo, Josee Bouchard, Jihoon Kim, Lucila
Ohno-Machado, Ravindra Mehta
Introduction: Acute kidney injury (AKI) is a well-recognized complication of critical illness encountered in
25-50% of ICU admissions and is associated with increased morbidity and mortality. Several studies have
established the relationship between small increments in serum creatinine and adverse events and
suggested that accurate identification of individuals at risk and early recognition of an AKI episode could
offer opportunities for interventions. Over the past decade, several risk stratification scores have been
developed to predict AKI in specific clinical settings (e.g., after cardiac surgery, contrast exposure,
hospital-acquired, general surgery and high-risk surgery). However, there are relatively few models
examining the clinical risk factors for the development of AKI among the intensive care unit (ICU)
population. We hypothesized that a risk stratification score based on routinely available clinical risk
factors would accurately predict AKI risk in an ICU population.
Methods: Our cohort consists of 742 patients admitted to medical-surgical ICU in a university hospital
between June 2006 and Dec 2008. Baseline risk factors were ascertained at ICU admission and
additional acute factors within the first 48 hrs of ICU stay. Patients were stratified as no risk, baseline
risk, acute risk, and enhanced risk. Incidence of AKI, need for renal replacement therapy (RRT) and
mortality were assessed among these risk groups. Separate risk score was developed using
multivariable regression coefficients based on combined baseline and acute risk factors in the training
cohort. Risk Score was further evaluated in a test cohort. The discrimination of the scoring model was
examined by the Area Under the Receiver Operating Characteristic Curve (ROC) and the model
calibration was evaluated by Hosmer-Lemeshow test.
Results: The overall incidence of AKI was 22.9% (164 cases). Patients classified as enhanced risk had a
higher incidence of AKI (31.1% vs. 9.1%; p < 0.001), higher mortality (10.1% vs.0.9%; p< 0.001) and need
for RRT (8.2% vs. 0.0%; p< 0.001) compared to patients with solely baseline risk. In the multivariate
model, chronic kidney disease (CKD), chronic liver disease, congestive heart failure (CHF), hypertension
(HTN), atherosclerotic coronary vascular disease (ASCVD), pH=7.30, nephrotoxin exposure, sepsis,
mechanical ventilation and anemia were identified as independent predictors of AKI and the c-statistic
for the model in the test cohort was .792 (.697-.887).
Conclusion: A risk classification system based on chronic comorbidities and acute events can identify ICU
patients at high risk to develop AKI and adverse outcomes within 48 hours of ICU admission. This risk
assessment tool could help clinicians to stratify patients for surveillance, prevention and early
therapeutic intervention.
106

NEW YORK POSTER FINALIST - RESEARCH Suchita J Mehta, MBBS
High Rates of Precancerous Cervical Lesions In Renal Transplant Recipients: Implications of Cancer
Screening
Suchita J Mehta1,Suzanne E. El Sayegh1,Morton J. Kleiner1, Kathleen Ahern2,Mario R. Castellanos1. 1.
Dept. of Medicine, Staten Island University Hospital, NY 2. Nursing Program, Wagner College, NY
Introduction: Immunosuppressive regimens improve survival of renal transplant recipients (RTR);
however, a long-term complication is increased risk of developing cancer. It is predicted that mortality
due to malignancy will exceed cardiovascular casues in the next twenty years. Human papillomavirus
(HPV) associated cancers of the genital tract are of particular interest, since they are sexually
transmitted and in theory preventable. Cervical cancer rates are high in RTR but the data on the natural
history of HPV infection in RTR are limited. Therefore, we investigate HPV and the development of
cervical neoplasia.
Methods: A review was conducted in Medline database for articles in English investigating cervical HPV
infection in RTR. Eligible studies included those that examined HPV infection by PCR testing and/or
obtained cervical biopsies. Three reviewers extracted the data and compared rates to the general
population.
Results: Out of 157 relevant citations, 12 met our inclusion criteria: 4 prospective studies included 231
RTR, 27.27% became HPV (+) and 13.2% that went for biopsy had a high grade dysplasia and 71.43% had
mild dysplasia. Six cross-sectional studies examined 252 RTR, 21.39% were HPV (+) and 19.76% had a
high grade dysplasia and 62.79% had mild dysplasia. Two retrospective studies included 276 patients,
only 25 RTR were sent for biopsy with 32% having high grade dysplasia and 60% had mild dysplasia. The
average duration of immunosuppression was 3.1 years to diagnose HPV or dysplasia. (See table below)
STUDY DESIGN NUMBER
OF
STUDIES
CROSS-SECTIONAL
STUDIES
Total RTR = 252
PROSPECTIVE STUDIES
Total RTR = 231
107
DURATION OF
IMMUNO-
SUPPRESSION
(IN YEARS)
RATE OF
POSITIVE
HPV DNA
6 3.75 21.39%
(40/187)
4 3.08 27.27%
(63/231)
RATE OF CERVICAL
DYSPLASIA
HPV OR MILD
DYSPLASIA
62.79%
(54/86)
71.43%
(30/42)
HIGH GRADE
DYSPLASIA
19.76%
(17/86)
13.2%
(7/53)

RETROSPECTIVE STUDIES
Total RTR = 276
GENERAL
POPULATTION
Conclusion: Cervical cancer screening guidelines in RTR are not based on published data.
Recommendations in RTR have been extrapolated from the general population. In our study, we
demonstrate in a large cohort of RTR that the HPV prevalence is similar to that of the general
population. However, the progression rates to high grade dysplasia are several folds higher at an
average duration of 3.1 years of immunosuppression. 13-32% of RTR biopsied had high grade dysplasia
compared to 0.8% in the general population rate and 60 to 71% had mild dysplasia compared to 0.5% in
the general population. The uptake of cancer screening is low in RTR , as proved by studies in the
past. Cervical cancer screening and prevention is important in RTR. Counseling should be aimed at
limiting risky sexual behaviors post transplantation.
108
2 3.85 NOT DONE 60%
N/A N/A 10% to
33%
(15/25)
32%
(8/25)
0.5% 0.8%

NEW YORK POSTER FINALIST - RESEARCH Girish N Nadkarni MD, MPH, CPH
Results of a Survey of Residents’ Attitudes on the Effect of New Work Hour Regulations on Informal
Teaching and Research among Residents
Girish N Nadkarni MD, MPH, CPH Narender Annapureddy MD Sumedh Hoskote MD Aneesha Shetty MD,
MPH Vijay Kanakadandi MD Bijal Mehta MD Ethan D Fried MD, MS, MACP
Introduction: The Accreditation Council for Graduate Medical Education (ACGME) implemented
substantial changes to resident duty hours starting July 2011. These have been met with differing levels
of agreement on their impact on resident wellbeing and their lives apart from work. The internal
medicine residency program at our institution has been in accordance with the new regulations for the
last 4 years. This study was aimed at assessing the attitudes of the residents towards the impact work
hour regulations have on informal teaching by residents and time available for research activities.
Methods: The survey was conducted electronically among the residents of a large, urban, communitybased
teaching hospital. All responses were anonymous. Residents provided responses to questions
about post-graduate year (PGY) status, country of graduation, demographics and various aspects of
patient care on medicine floors. Informal teaching included activities that residents undertake to teach
interns and/or medical students outside the scope of formal didactic teaching. A Likert type scale with
responses ranging from “Strongly Disagree” to “Strongly Agree” was used to assess the responses. The
responses were quantified numerically and analyzed using Chi-square and Student T-test.
Results: A total of 98 residents out of 160 completed the survey. We had a response rate of 61.3%. Of
the responders 39% were interns; 30.5% were PGY-2 and 30.5% were PGY-3’s. 61% of responders were
male and the mean age was 28 years. Fifty-seven percent were international medical graduates (IMG);
34% were US medical graduates (USMG) and 9% were US citizens who graduated from a medical school
outside the US (US-IMG). When PGY-3 residents were asked if the time constraints allowed them
sufficient time to teach their interns, 41% replied in the affirmative. This was significantly different
depending on level of residency, with a 70% of PGY-3s agreeing compared to 53% of PGY-2s (p

NEW YORK POSTER FINALIST - RESEARCH Gopichand Pendurti, MBBS
Activity of Rituximab (RIT) and Ofatumumab (OFA) against mantle cell lymphoma (MCL) in vitro in
MCL cell lines.
Gopichand Pendurti, MBBS Other Authors:Matthew J.Barth, Cory Mavis, Myron S.Czuczman, Francisco J.
Hernandez-Ilizaliturri. Department of Medicine, Roswell Park Cancer Institute.
Introduction: Mantle cell lymphoma (MCL) is an aggressive form of non-Hodgkin lymphoma (NHL) that
frequently presents with advanced stage disease. The addition of Rituximab, a monoclonal anti-CD20
antibody, to high dose chemotherapy regimens often followed by stem cell transplant has improved
outcomes, but survival still remains low at 3-5 years. Novel agents are needed to improve outcomes in
MCL. Ofatumumab is a fully human anti-CD20 monoclonal antibody directed against a novel epitope on
the CD20 antigen. OFA has been shown to be more potent than RIT against B-NHL cells in pre-clinical
investigations. OFA is FDA approved for the treatment of CLL that is fludarabine and alemtuzumab
refractory or with bulky disease resistant to fludarabine and is being investigated in clinical trials in NHL.
In order to characterize the activity of Ofatumumab against MCL, we performed pre-clinical
investigations into the activity of OFA against MCL cell lines
Methods: We compared the activity of rituximab and ofatumumab in the MCL cell lines Mino, JeKo, REC-
1 and Z-138. The activity of RIT and OFA were compared using functional assays including complementmediated
cytotoxicity (CMC) and antibody-dependent cellular cytotoxicity (ADCC) assays. Tumor cells
were labeled with 51 Cr prior to treatment with RIT or OFA at a dose of 10ug/mL and peripheral blood
mononuclear cells (ADCC) or human serum (CMC). 51 Cr-release was measured and the percentage of
lysis calculated. Mean lysis was compared using a t-test.
Results: OFA showed improved activity compared to RIT in complement mediated cytotoxicity assays
using MCL cell lines (Mino: 65.9% vs 0.5% ; JeKo 43.9% vs 13.3% ; REC-1 25.4% vs 4.7% ; Z-138: 56.4% vs
0.65%; all p-values

NEW YORK POSTER FINALIST - RESEARCH Aye Myat Myat Saw, MD
Differences in Hormone Receptor Status by Age group, Race and Ethnicity among Women with
Primary Breast Cancer in an Inner City Teaching Hospital
Aye Myat Myat Saw, MD, Rajnish Khillan MD, Wah Wah Htun MD, Mark Sonnenschine DO
Introduction: Primary breast cancer (BC) is the leading cause of death among female cancer patients.
Studies evaluating expression of hormonal receptors in different races have had variable results: African
American (AA) BC patients mostly have negative estrogen receptor (ER)/progesterone receptor (PR),
whereas Hispanic (H) BC patients had ambiguous results. Asian (A) BC patients had more negative ER/PR
compared to their non-Hispanic white (NHW) counterparts. Age at diagnosis of BC can also predict
diverse receptor expression. This retrospective observational pilot study at an inner city teaching
hospital was done to determine differences in hormone receptor status by age group, race and ethnicity
among women with primary BC.
Methods: Patients were identified with ICD-9 diagnosis code of primary BC from January 2007 to July
2011. Women with borderline or unknown ER/PR/Her2 neu receptors status were excluded. Patients
were divided into 4 subtypes: ER/PR + Her 2-, ER/PR + Her 2 +, ER/PR - Her 2 +, ER/PR - Her 2-. Because
this was a pilot study, statistical significance was not calculated.
Results: Race/ethnicity of the 141 patients meeting study criteria were H 73, AA 23, NHW 35, A 10.
Most women in all groups had invasive ductal carcinoma: H 64%, AA 74%, NHW 67%, and A 75%. 64% of
women were 59 years old or younger at time of diagnosis. Overall, 33% had AJCC Stage I breast cancer
at the time of diagnosis, and 33% Stage II, compared to 41% of Hispanics with Stage I. Most patients
were positive for ER: H 74%, AA 63%, NHW 64%, and Asian 75%. PR receptor positivity was as follows: H
56%, AA 41%, NHW 61%, and Asian 67%. Her2-neu receptor was positive as follows: H 25%, AA 33%,
NHW 19%, and Asian 60%. 21 patients (15%) had triple receptor negative breast cancers (H 9, NHW 8,
AA 4). Our Hispanic patient population compared with SEER data was as follows: ER/PR +/ Her 2-
subtype 56% vs 50-70% in SEER; ER/PR+Her2+ and ER/PR-Her2+ subtypes 32% vs 10-20%. Our Asian
population had higher Her2 receptor positivity (60 % vs 10-20%). African Americans had less ER/PR +/
Her 2- subtype, 44% vs 50-60%.
Conclusion: Our population was younger at diagnosis in comparison to the national average of 61 years
old. Hispanics were more likely to have AJCC Stage I breast cancer at the time of diagnosis. Hispanics
were also more likely to have Her2 + subtypes as compared to SEER data. Larger studies should be done
to further investigate such differences.
111

NEW YORK POSTER FINALIST - RESEARCH Hemant Sindhu, MD
HDAC Inhibitor Therapy in CLL: A Closer Look at Classes of Inhibition
Hemant Sindhu, MD (Associate), Mohammed I Kafeel, MD, Jen Wang, MD
Introduction: Elevated histone deacetylase (HDAC) enzyme activity have been implicated in the
development of cancer, including leukemia and solid tumors. Although there are in vitro and in vivo
studies using HDAC inhibitors (HDACi) in chronic lymphocytic leukemia (CLL), none of the studies have
yet profiled the levels of expression of various HDAC isoenzymes in CLL. The increased resistance to
belinostat in response to HDAC1 depletion has been reported. Therefore, phenotyping the specific
isoenzyme may be the important in tailoring the treatment of CLL by using more specific HDAC
inhibitors.
Methods: Patients were diagnosed as having CLL according to the International Workshop on CLL (IW-
CLL) and the National Cancer Institute–sponsored Working Group on CLL (NCI-WG) criteria. Quantitative
RT-PCR for HDAC isoenzyme were measured in 32 patients with CLL and compared with 17 normal
volunteer controls. ZAP-70, CD38, CD44 also were assayed and correlated to HDAC isoenzyme levels.
Student’s t-tests were employed to compare the difference of HDAC values between CLL patients and
controls. Pearson’s X2 test were used to correlate HDAC isoenzyme levels, Rai stage and CD44
expression levels.
Results: The results showed: 1) HDAC isoenzyme levels in CLL were significantly increased in class 1 of
HDAC 1 and 3, class II of 6, 7, 9, 10 and class III of SIRT 1 and 6; 2) Higher expression of HDAC isoenzyme
levels were found in ZAP-70 positive than ZAP-70 negative patients and CD44 expression levels were
correlated to HDAC isoenzyme expression levels in the majority of HDAC classes.
These results suggest: 1) in CLL, elevated HDAC isoenzyme activity is not restricted to one class which is
whydah inhibitor therapy may need to be directed to more than one specific class of HDAC; 2) higher
HDAC expression activity may indicate a poor prognosis and more advanced disease stage (through
indirect evidence) since higher values were found in patients with ZAP-70 positive and higher CD 44
expression levels.
Conclusion: We found that in CLL patients, most of the HDAC isoenzyme levels including class I, II and III
were increased 2.1 to 4.7 fold. These findings indicate that in CLL patients, the over-expression of HDAC
isoenzymes is not restricted to one class and this may partly explain the reasons for the poor response
of the compound MGCD0103 (an orally available class I and class IV HDAC inhibitor) in a Phase II study.
Since HDAC inhibitors have not only chromatin modulating effects but also have other tumor inhibiting
effects, it may be necessary, in future tirals, to use HDAC inhibitors having pan-inhibition of HDAC
isoenzymes rather than one specific class.
112

NEW YORK POSTER FINALIST - RESEARCH Atsushi Sorita, MD
Transition of Routine AM Blood Draws to Midnight Blood Draws: An Assessment of Timely Test
Results and the Impact on Patient Satisfaction in an Urban Teaching Hospital
Atsushi Sorita, MD Aaron Ronald Patterson, MD, MBA, MA Patrick Landazuri, MD Christina Lee, MD
Stacy De-Lin, MD Diana Huang, MD Colleen Fischer, RN Latha Sivaprasad, MD, FACP
Introduction: Routine blood tests are usually performed during the early morning hours at hospitals
across the country. Timely review of those laboratory tests during morning rounds is critical for safe and
efficient patient care. However, availability of those results for rounds is variable. At our institution,
both the batched approach of morning blood specimens and high demands for early test results
availability resulted in a heavy workload for laboratory and nursing staff. To explore possible solutions to
this problem, an interdisciplinary group comprised of medical, nursing, and laboratory staff assessed the
feasibility of routine midnight versus morning (6AM) blood draws.
Methods: Patient preference for midnight or morning blood draws was assessed using a questionnaire.
The chi-square test was used to compare survey results with a random distribution. Routine laboratory
tests were ordered at midnight from August 16 – 31, 2011 on one medicine floor. All 6AM and midnight
orders of complete blood cell counts and basic/comprehensive metabolic panels on the study floor were
analyzed. A house staff survey was also conducted after the study period.
Results: A patient survey (N=100) revealed 41 patients preferred midnight blood draws, 22 preferred
morning blood draws, and 37 had no preference (p

NEW YORK POSTER FINALIST - RESEARCH Ehtesham Ul Haq, MBBS
Detection Of Severe Left Ventricular Hypertrophy By Different Electrocardiographic Criteria
Ehtesham Ul Haq, MBBS Co authors: Vinod Gundu, MBBS, Tamas Szombathy, MD, FACC
Introduction: Left ventricular hypertrophy (LVH) refers to increase in size of the myocardial fibres in the
main cardiac pumping chamber. LVH can be in response to chronic volume or pressure overload.
Objective of this study was to compare the different electrocardiographic criteria for diagnosis of severe
LVH.
Methods: Electrocardiographic criteria used for calculating LVH were Sokolow-Lyon criteria, Cornell
voltage index and Romhilt-Estes point score system. A total of 71 patients (37 men and 34 women) with
documented LVH on echocardiogram (By ASE criteria) and EKG were selected. All the patients with
bundle branch blocks, WPW syndrome and Atrial Fibrillation on EKG were excluded. 80 % of the patients
in the study had hypertension. 13 out of 71 patients had severe LVH on echocardiogram and 58 had non
severe LVH. Electrocardiographic criteria including Sokolow-Lyon, Cornell and Romhilt-Estes indices
were determined in all patients. Positive and negative predicitive values for each electrocardiographic
criterion and their combinations were calculated. Logistic regression analysis including clinical variables
such as age, sex, weight and hypertension was performed to ascertain the predictors of LVH for all
electrocardiographic criteria. Mean age of the patients included in the study was 62.41 years (SD 14.22).
Mean weight was 80.5 kg (SD 17.23).
Results: The proportion of patients with severe LVH on echocardiogram was 18% (n=13) in this study.
The positive predictive value for severe LVH was 13%, 24% and 14% by using Sokolow-Lyon, Cornell and
Romhilt-Estes criteria respectively.
Combination of these criteria did not increase the performance of the test. Cornell voltage index had the
highest negative predictive value (90%) for severe LVH and it was an independent predictor of severe
LVH. Negative predictive values for Sokolow-Lyon and Romhilt-Estes criteria were 61% and 67%
respectively.
Conclusion: Cornell voltage index was found to have best negative predictive value among all the three
EKG criteria. Among the electrocardiographic criteria for LVH, Cornell voltage index may be the most
useful to exclude severe LVH.
114

NEW YORK POSTER FINALIST - RESEARCH Xi Zheng, MD, PhD
Induction Of Cytochrome P450 3A4-dependent Vitamin D3 Metabolism And Altered Mineral
Homeostasis
Xi Zheng MD,PhD 1 2, Paul Mustacchia MD 2, Kenneth Thummel PhD 1* 1 Department of
Pharmaceutics, University of Washington, WA 2 Department of Medicine, Nassau University Medical
Center, East Meadow, NY
Introduction: Vitamin D3 is critical for the regulation of calcium and phosphate homeostasis. Long-term
treatment with certain drugs (e.g. rifampin, phenobarbital, carbamazepine) has been reported to cause
drug-induced osteomalacia. Many of these drugs are well-known inducers of cytochrome P450 3A4
(CYP3A4). Recently we reported that catalytic activity of CYP3A4 towards 1,25(OH)2D3 and 25OHD3, to
form 24R,25(OH)2D3 and 4b,25(OH)2D3 respectively, which might contribute to vitamin D inactivation.
The aim of this pilot study is to investigate the effect of short-term rifampin therapy on vitamin D
metabolism and mineral homeostasis.
Methods: A total of six healthy volunteers were recruited and completed the study. Each received 7
days of rifampin treatment (600 mg/day). Multiple blood samples and random urine were collected pre-
and post-treatment. 1,25(OH)2D3, 24R,25(OH)2D3, 4b,25(OH)2D3, 25OHD3, calcium and phosphate in
blood, as well as calcium, phosphate and creatinine in urine, were measured using LC/MS/MS or
standard clinical laboratory procedures. Similarly, in vitro the human intestinal cell line, LS180, and
human hepatocytes were treated with rifampin or rifampin + DHB (a selective CYP3A4 inhibitor).
Vitamin D receptor (VDR)-targeted gene expression and formation of vitamin D metabolites were
measured. Statistical comparison of the pre- vs post- treatment measurements were conducted with
SAS.
Results: In humans, rifampin treatment caused reductions in the concentrations of 25OHD3 (-11%, p <
0.05) and 24R,25(OH)2D3 (-13%, p < 0.05), but had insignificant effect in the 1,25(OH)2D3 level (-10%,
p=0.07). In contrast, there was a significant 2-fold increase in the plasma 4b,25(OH)2D3. Interestingly,
decreased serum calcium were observed in all subjects. Serum calcium and phosphate were significantly
decreased by 1.9% (9.27 vs 9.36 mg/dL, p = 0.004) and by 5% (3.75 vs 3.96 mg/dL, p = 0.01),
respectively. In the urine, the creatinine-normalized phosphate excretion (UPi/UCr), increased by 50%
(0.18 vs 0.26, p = 0.04). In vitro, in human intestinal cell line LS180, rifampin treatment significantly
decreased vitamin D-mediated stimulation of TRPV6 expression, which is considered as a gatekeeper
for intestinal calcium absorption. In human hepatocytes, treatment with rifampin led to a 8-fold
increase in 4b,25(OH)2D3 formation, but no change in 24R,25(OH)2D3. Lastly, these in vitro effects of
rifampin were reversed by addition of DHB, which is a selective CYP3A4 inhibitor and an active
ingredient in grapefruit juice.
Conclusion: Short-term treatment of rifampin in humans selectively induced CYP3A4-dependent vitamin
D metabolism and altered mineral homeostasis. Together with the in vitro results, this study suggests
that induction of CYP3A4 could lead to reduction in oral calcium absorption and stimulation in renal
115

excretion of phosphate. If these effects persist in a long term, it could cause drug-induced osteomalacia.
Grapefruit juice, containing DHB, a potent CYP3A4 inhibitor, could potentially prevent drug-induced
osteomalacia/vitamin D deficiency.
116

NEW YORK POSTER FINALIST - RESEARCH Dean Padavan, MD
Dietary Supplements Among Division I College Athletes in New York
Padavan, D. MD Lenox Hill Hospital, Padavan, Sa. MD Mount Sinai Hospital, Graham, R. MD Lenox Hill
Hospital
Introduction: Athletes use supplements including vitamins in hopes of improving their athletic
performance, yet there is insufficient research to support their use. The purpose of this study was to
document the use of supplements in Division I college athletes in New York, reasons for use, if they are
influenced by diet, the doses used and gender differences.
Methods: Seventy-four athletes from two Division I schools were surveyed while undergoing pre-
participation physicals at Lenox Hill Hospital from August 2010 to October 2010. They were given an
anonymous questionnaire developed by the authors. The response rate of the questionnaire was
approximately eighty percent (Fifty-nine athletes).
Results: Forty-four females and fourteen males participated in the study (one participant did not
identify their gender). The average age was 19.78 and these athletes competed in basketball, soccer,
golf, tennis, water polo, swimming, lacrosse and track. Thirty-nine percent of the athletes admitted to
taking vitamins (45.4% of the female athletes, 21.4% of the male athletes) with multivitamins, vitamin C,
and biotin being the most consumed (20%, 19%, and 5% respectively). Approximately fourteen percent
of athletes took supplements other than vitamins (15.9% of the female athletes and 7.1% of the male
athletes) with fish oil being the most consumed followed by creatine (5% and 3% of all athletes
respectively). Ten percent of athletes took both vitamins and other supplements together and they were
all female. There were three vegetarian female athletes and all of them took vitamins. The most
common reasons for taking supplements other than vitamins were to supplement diet (4 out of 8
athletes) followed by delay fatigue, improve immunity and build muscle (3 out of 8 athletes for each).
The doses of the supplements consumed were only known by two athletes.
Conclusion: Nearly half of Division I college athletes surveyed take supplements and most are unaware
of the dosages they consume. There may be a dietary influence on their use. This study suggests the
need for health care professionals to screen athletes on the use of supplements and educate them
regarding their potential risks and benefits.
117

OHIO POSTER FINALIST - RESEARCH Yun Xia, MD
Gout Risk Factors and Treatment among Chronic Kidney Disease Patients: A Hospital Based Cross
Sectional Study
Yun Xia, MD, Yanli Fan, MD, David Gemmel, PhD, Erdal Sarac, MD
Introduction: Gout has doubled in prevalence in the United States. Recent studies have proposed
hyperuricemia and gout as risk factors for progression of chronic kidney disease (CKD). This study
investigated the prevalence of gout in patients with CKD and compared the current practice patterns to
recommendations and guidelines put forward by the European League Against Rheumatism (EULAR).
Methods: A total of 1,827 patients admitted between 2009 and 2010 at St. Elizabeth Health Center with
a diagnosis of chronic kidney disease were included by database search using ICD-9 codes. Patients were
divided into two groups: CKD with gout and CKD without gout. Data collection included age, sex, and
comorbid diagnoses. A subset of 50 patients was randomly selected to compare the treatment they
received with EULAR guidelines.
Results: The prevalence of gout in the hospitalized patients with CKD was 251/1827 (13.7%, 95% CI 12-
15%). Males exhibited higher rates of gout: 150/964 (15.6%) vs. 101/863 (11.7%), respectively (X2=5.40,
p=0.02). Gout prevalence increased with age - highest prevalence was observed among patients age 71
to 80 years, with elderly males exhibiting even higher rates of disorder (17% in female and 26% in male).
CKD patients with and without gout has a prevalence rate of coronary artery disease of 41.8% vs. 36.3%
(X2=2.62, p=0.11). Both hyperlipidemia and diabetes mellitus were higher in the CKD patients with gout:
46.2% versus 38.7% (X2=4.71, p=0.03), and 29.8% versus 23.8% (X2=3.99, p=0.04). Hypertension was
higher in patients with gout, 82.5% versus 78.1% (X2=2.20, p=0.14). Only 65% of CKD patients with gout
were treated following The European League Against Rheumatism (EULAR) guidelines.
Conclusion: This study reveals a high prevalence of gout in patients with CKD. Male sex, advanced age,
diabetes, and hyperlipidemia were significantly associated with gout among CKD patients. Treatment for
gout was sub-optimal in the subset of examined CKD patients. Allopurinol, a traditional treatment for
gout, which has dosing restrictions for renal impairment, may explain this finding. Newer treatment
modalities for gout may change these findings in the future. Greater awareness is needed to improve
the management strategies for gout in CKD patients.
118

OHIO POSTER FINALIST - RESEARCH Ahmed M Ibrahim, MD
Predictors of Major Adverse Cardiac Events in Patients with Carbon Monoxide Poisoning
Ahmed Ibrahim, MD MSc Other authors:Osama Amro MD , Shadi Mayasy MD ,Khaldoon Shaheen MD, ,
Motaz Baibars MD,Robert Steele, MD,FRCP Joseph Sopko,MD FCCP,Srinivas Merugu ,MD FACP Keyvan
Ravakhah, MD FACP, M Chadi Alraies MD FACP
Introduction: Carbon monoxide (CO) is the most common cause of death from poisoning in the United
States. Cardiovascular complications and their contribution to acute outcomes are yet to be defined.
Methods: We retrospectively reviewed all the cardiovascular manifestations of CO poisoning in patients
presented to St Vincent Charity Medical Center, the regional center for CO poisoning treatment
between the periods of January 2009 to September 2011. Patients demographics, comorbidities,
electrocardiograms (EKG), laboratory results and echocardiograms were identified from chart review
and retrieved for analysis.
Results: We identified 47 patients, mean age 49.3 years and majority were male (72%). The mean
hospital stay was 2.6 days. The average carboxyhemoglobin (COHb) level was 24.9%. 20% of cases were
intentional poisoning, 19% were unconscious on presentation (UOP) and 20% were
intubated. Cardiovascular risk factors in these patients were diabetes mellitus 9%, hypertension (HTN)
36%, dyslipidemia 6%, smoking 32% and family history of premature coronary artery disease 4%.
Obesity was present in 19% with 4% having documented history of CAD and 14% with cocaine abuse
prior to admission. Troponin I was found to be greater than 0.2 ng/mL in 37 % of patients and more than
1 ng/mL in 17%. Ischemic EKG changes were found in 4 % of patients. Corrected QT interval (QTc) was
prolonged (>440 msec) in 68% of patients. Echocardiogram was done in 9% of patients and 4% had
depressed left ventricular ejection fraction which recovered after hyperbaric oxygen treatment. 92% of
patients received treatment with hyperbaric oxygen (HBO). Two patients died by anoxic brain injury
that was unrelated to their cardiac status. There was no correlation between COHb level and troponin
or QTc (r = -0.2 and 0.02 respectively). UOP and intubation were the main predictors of significant
myocardial injury with 55.5% of UOP group (P=0.002) and 62.5% 0f intubated patients having a troponin
I > 1 ng/mL (P=0.001). HTN was the only predictor of significant QTc prolongation with 88% of
hypertensive group having a QTc >440 msec (P=0.016).
Conclusion: Myocardial damage in patients presenting with CO poisoning is common and manifested by
increased troponins and prolonged QTc. There is no correlation between COHb level and myocardial
injury. In these patients, UOP and intubation are the only two significant predictors of troponins
elevation while HTN is associated with more QTc prolongation. This damage is usually transient and is
reversed with urgent HBO therapy.
119

OHIO POSTER FINALIST - RESEARCH Ali Raza, MD
The IL-2 Levels in Supernatants of Intra-Epithelial Mucosal Lymphocytes Stimulated in Vitro with Anti-
CD3 were Significantly Higher in Healthy Adults Compared to the Patients with Inflammatory Bowel
Disease (IBD).
Ali Raza, MD. Shata, Mohamed Tarek Ahmed, Kashif Navaneethan, Udayakumar Abdel-Hameed, Enass
Giannella, Ralph A.
Introduction: Inflammatory Bowel Disease (IBD) is characterized by an unusual and exacerbated
immune response in gastrointestinal (GI) tract. Intestinal inflammation results from shift of balance
away from immunosuppressive responses. Recently, role of newly discovered T-helper cells have been
described in the pathogenesis of IBD. Of these, T-regulatory (T-reg) cells and T-helper 17 (Th-17) cells
have been the focus of attention due to their immunosuppressive and proinflammatory properties
respectively. IL-2, produced by various lymphocytes, is a potent stimulator of the T-reg cells. Animal
models have demonstrated significant intestinal inflammation in IL-2 deficient hosts. Similarly, blocking
IL-2 results in enteritis in mice. Our study objective is to compare the IL-2 levels in plasma and the intraepithelial
mucosal lymphocytes in healthy adults and IBD patients.
Methods: In our on-going prospective cohort study, we have enrolled 10 patients with either Ulcerative
Colitis (UC) or Crohn’s Disease (CD) and 13 healthy controls. We measured the plasma levels of IL-2 in all
the IBD patients and healthy controls using ELISA assays according to the manufacturer’s instructions.
Similarly, IL-2 levels were measured in the supernatant of intra-epithelial lymphocytes (IEL) isolated
from rectal biopsy from all IBD patients and controls after in vitro stimulation with anti-CD3 for 48
hours.
Results: Plasma levels of IL-2 were compared in healthy controls (Mean= 1.099 pg/ml) and IBD patients
(Mean= 1.14 pg/ml) using Wilcoxon 2 sample test, which did not show any significant difference (Pvalue=
0.9766). The IL-2 levels in the supernatant of stimulated IEL in controls (Mean= 1440.91 pg/ml)
and IBD patients (Mean= 76.82 pg/ml) were compared using the same test, which showed significantly
higher levels in controls compared to IBD patients (p-value= 0.006).
Conclusion: Mucosal epithelial levels of IL-2 were significantly higher in healthy controls compared to
IBD patients upon T cell stimulation. IL-2 may suppress the proinflammatory responses by stimulating Treg
cells growth and function. This makes IL-2 an important therapeutic target for future biological
agents.
120

OHIO POSTER FINALIST - RESEARCH Shoshana Jo Weiner, MD
The Association Between Free PSA Velocity and Prostate Cancer Diagnosis by Biopsy
Shoshana Jo Weiner, MD Jianbo Li, PhD Osama Zaytoun, MD Stephen Jones, MD
Introduction: Screening for prostate cancer with total serum prostate specific antigen (PSA) has not
been shown to improve the mortality of prostate cancer patients. This has led to a search for new
biomarkers. To date, no one has evaluated the relationship of free PSA (fPSA) velocity, the change in the
concentration unbound serum PSA over time, to prostate cancer diagnosis.
Methods: All patients who presented to the Cleveland Clinic between 2000 and 2009 who had at least
two prostate biopsies, with one negative biopsy, were considered for the study. A case-control study
was conducted to compare free PSA velocity between cases, who are patients diagnosed with prostate
cancer (Gleason score > 0) after a previously negative biopsy, and controls, who are patients with two
sequential negative biopsies. Univariate analyses were conducted to compare absolute differences and
velocities of fPSA and PSA between cases and controls. Age, race, prostate volume, positive digital
rectal exam and the pathological features of prostatic intraepithelial neoplasia (PIN), atypia and
inflammation were compared between cases and controls for each biopsy. An iterative logistic
regression model was constructed in order to compare fPSA velocity between cases and controls. All
statistics were considered significant at a p-value of 0.004 with the application of the Bonferroni
correction.
Results: Forty-nine cases and 128 controls had the necessary fPSA values, which were restricted to being
within two months of each biopsy. In addition, all biopsies required at least 10 cores and needed to be
at a minimum one year apart from the previous biopsy. Our population was mainly Caucasian
(86%). The median ages for the first and second biopsies were 62 (IQR: 56, 67) and 64 (IQR: 58, 69),
respectively. 9 (18%) of the positive biopsies had a Gleason score of 7 or greater, and most were
Gleason score 6 (78%). There was no significant difference in the fPSA velocity between cases (-0.21,
IQR: -2.32, 1.06) and controls (0, IQR: -1.73, 0.81). For the second biopsy, samples from cases had
significantly more PIN (49% versus 26%,p-value= 0.003) than controls, and controls had significantly
more inflammation (69% versus 43%, p-value= 0.002). fPSA velocity was not significantly associated
with having a positive prostate cancer biopsy in the logistic regression model (Odd ratio: 0.92; 95% CI
0.75-1.12), which adjusted fPSA for PSA velocity and absolute change in PSA.
Conclusion: fPSA velocity is not associated with a positive prostate biopsy for cancer. This may be due
to confounding pathological findings on biopsy such as inflammation.
121

OKLAHOMA POSTER FINALIST - RESEARCH Howard Y Lee, DO
Drug Screen Profile of Patients on Chronic Pain Medications.
Howard Y Lee, DO Lyn Rojas, MD William Yarborough, MD
Introduction: Narcotics are used extensively for chronic pain management in the United States. Opioid
misuse occur frequently in chronic pain patients in a pain management program within an academic
primary care practice. Narcotic abuse has been demonstrated in 9% to 41% of patients receiving chronic
pain management. Illicit drug use has been reported in 14% to 34% of patients in chronic pain
management settings. Structured monitoring for opioid misuse appears to be one of the important
aspects of effective pain management. Narcotic contracts have been used to help ensure compliance,
but there is limited empirical evidence for the effectiveness of opioid contracts. We propose to
determine the drug screen profile and determine incidence of illicit drug use in patients on chronic pain
management with the University of Oklahoma (OU) in Tulsa Internal Medicine Clinic.
Methods:The records of all adult patients on chronic pain management with a diagnosis of back pain
that have a narcotic contract with OU Internal Medicine seen in the clinic between June 1, 2010 and
May 31, 2011 were reviewed. Each chart was checked whether the patient had a urine drug screen. In
those patients who have had a drug screen, we checked if the result was consistent with their
medication profile. It was also checked for presence of illicit substances. The prevalence of drug abuse
was then obtained.
Results: In the scheduled time duration, eight hundred sixty four patients were seen in the clinic for
back pain medication refill. One hundred nineteen (119/864) patients had urine drug screen. Sixty four
(64/119) patients had inconsistent drug screen. Of the sixty four patients who had inconsistent drug
screen, twenty six patients (26/64) were positive for marijuana, (2/64) two patients were positive for
methamphetamine, (2/64) two were positive for both marijuana and methamphetamine, and one
(1/64) was positive for cocaine.
Conclusion: Majority of patients on chronic pain management never had a urine drug screen. There is a
prevalence of fifty four percent for inconsistent drug screens and twenty six percent for illicit drug use in
patients on chronic pain management in spite of having a narcotic contract. It is suggested that drug
screening should be done periodically on these patients.
122

OKLAHOMA POSTER FINALIST - RESEARCH Jason Shultz, MD
Smokers on a Fixed Income: Understanding the Long Term Health and Financial Consequences of
Smoking
Jason Shultz MD (Associate); Martina Jelley MD FACP
Introduction: Smoking is the number one cause of preventable death in the United States and
worldwide. Approximately 440,000 Americans and 5 million people worldwide will die each year from
smoking related illnesses. The long term adverse health effects of smoking are very well publicized, yet
a significant proportion of Americans still smoke and every year millions more begin smoking for the first
time. Prior studies have shown that financial incentives for smoking cessation significantly increased
the the rates of smoking cessation.
Methods: Internal medicine clinic and hospital patients identified as current smokers were surveyed
regarding their smoking history and financial status. Only patients who were living on a fixed income
were included. Each patient was questioned regarding their understanding of the adverse health risks
followed by questions related to the amount of money spent on cigarettes. Finally, each participant was
asked a question to estimate the amount of money an average smoker would accumulate should they
invest their money over the course of their smoking life versus spending it on cigarettes.
Results: A total of 25 patients were identified and completed the survey. It was determined that all of
the participants demonstrated a sufficient understanding of the long term health adverse effects
associated with smoking such as cancer, heart disease, stroke and lung disease. However, patients
significantly underestimated the cumulative wealth potential had they invested the money they spent
on cigarettes instead. On average, the respondents underestimated this figure by $492,970.
Additionally, the average smoker surveyed spent nearly 20% of their total monthly income on cigarettes
and had reported virtually no savings.
Conclusion: The findings of this survey suggest that smokers who live on a fixed income have a limited
understanding of the true long term financial consequences of their smoking habit. As demonstrated in
prior studies, people often respond to financial incentives to quit smoking. Perhaps, an increased
awareness of the true financial impact of smoking on one’s personal wealth would help improve
smoking cessation and prevention efforts. Since almost 60% of new smokers are under the age of 18, a
shift to increase emphasis on the long term financial impact in addition to adverse health effects may be
more effective.
123

OKLAHOMA POSTER FINALIST - RESEARCH Vishal Mundra, MD
Impact of an Electronic Template on Clinicians Adherence to Follow Guidelines for Diabetes Care
Vishal Mundra, MD Shadi Yaghoubian, MS3, Viet Nguyen, MD, Darby Sider, MD, Jose Muniz, MD,
Carmen V Villabona, MD
Introduction: Diabetes mellitus (DM) was the seventh leading cause of death in 2006. The number of
patients is expected to double by 2050. Simple non-adherence to follow guidelines by physicians is a
significant source of morbidity and mortality. Our goal was to study the impact of an electronic template
on adherence to follow ADA guidelines for diabetes care by general internist.
Methods: We designed an electronic template based on the 8 point ADA guidelines for management of
diabetes type 2 including: glycosylated hemoglobin (HgbA1c) assessment, blood pressure (BP), lipid
control, smoking cessation counseling, diabetic foot exams, pneumococcal vaccination (PCV), renal
assessment and annual retina exam. The template was used by physicians for 6 months and a preintervention
control group was randomly selected independent of age and sex variable from existing
patients database.
Results: Our intervention group consisted of 212 subjects; they were compared with a control group of
154. Significant improvements were detected in HbA1c testing (57.5% vs. 94.1%; p

OKLAHOMA POSTER FINALIST - RESEARCH Vishal Mundra, MD
Is Risk Factor Control and Recommended Guideline Based Medical Treatment Optimal In Non-
Obstructive Coronary Artery Disease? A Retrospective Veterans Affairs Study.
Harsh Golwala, MD, Tarun W. Dasari, MD, MPH, Michael Koehler,MD, Siddharth Wayangankar,MD,
Aneesh Pakala , MD, Eliot Schechter,MD,FACC, Pedro Lozano, MD,FACC,FAHA, Mazen S. Abu-Fadel
,MD,FACC, Faisal Latif,MD,FACC, & Udho Thadani, MD,FRCP, FACC, FAHA
Background: Aggressive risk factor control and evidence based medical therapy is recommended for
treating patients with coronary artery disease (CAD). While it is assumed that obstructive CAD (OCAD)
patients usually achieve such targets, data in non-obstructive (NOCAD) CAD patients is scant. We
compared risk factor control and use of evidence based medical therapy in patients with NOCAD and
OCAD.
Methods: Patients who had undergone coronary angiography, between January 2006- June 2006 at the
Oklahoma City VA Medical Center, and in whom one year follow-up data was available, were included.
Demographic, clinical, laboratory and medical treatment data were compared between NOCAD & OCAD
groups at baseline and 1 year. Non-parametric Wilcoxon Sum rank test was used to compare means and
chi-square tests for comparing proportions, at a significance level of 0.05.
Results: Of the 354 patients who had coronary angiography. 222 (63%) had follow up data available at
12±2 months. At baseline, mean age in the NOCAD (n=119) and OCAD (n= 103) groups was similar.
There was a lower prevalence of hypertension (81% vs. 91%) and heart failure (17% vs.28%) (p

OREGON POSTER FINALIST - RESEARCH Jonathan Rogers, MD
Malaria Prevention in Informal Settlements: Is There a Role for Mosquito Coils?
Jonathan Rogers, MD
Introduction: Nairobi is considered a low risk area for malaria transmission (CDC, 2011), likely due to
high altitude and urban land use. However, malaria ranked as the second highest contributor to
outpatient morbidity in Nairobi, accounting for 10.6% of acute illnesses. The burden is estimated to be
even higher in informal settlements. Prior surveys revealed an unmet need for malaria prevention in
Nairobi. Thus, to identify preventive measures associated with a decreased risk of malaria in informal
settlements, we conducted a case control study in Nairobi, Kenya.
Methods: During April of 2009, cases were identified from clinic patients presenting with malaria in
Nairobi’s Kawangware settlement. P. falciparum parasitemia was confirmed by lab technician by
microscopic examination of blood smears. As a comparison group, patients presenting for routine health
maintenance were surveyed. Those patients presenting with symptoms suggesting infection were
excluded, unless they had a negative blood smear. The survey contained questions on demographics,
malaria prevention, exposure history, and sanitation. This was provided in English, Swahili, and verbally
for illiterate patients. To identify key covariates associated with a risk of malaria, univariate analysis was
used to calculate Pearson’s chi square p value (SPSS). For multivariate analysis, logistic regression was
performed to adjust for age and sex.
Results: During the study period, 45 cases and 68 controls were surveyed. Eight controls and zero cases
refused. Baseline demographic characteristics differed significantly as cases had a much higher
proportion in 0-19 age group (56% versus 27%, p value=0.003), but sex and tribe were not significantly
different. Use of mosquito coils differed significantly, used by 18% of cases and 42% of controls (odds
ratio 0.31, p=0.01), and remained significant after accounting for age and sex (p=0.03). Proximity to
stagnant water, such as open buckets, public toilets, irrigation systems, was also significantly associated
with malaria positivity by univariate analysis. Insecticide treated nets were not significantly associated,
although there was a trend for reduced risk with an odd’s ratio of 0.65 (confidence interval 0.29-1.45).
Conclusion: These results demonstrate an association between mosquito coil use and malaria risk.
Mosquito coils have been shown to reduce insect bites through repellent effect, but there are no
prospective randomized trials assessing the relationship with malaria transmission. Observational
studies on coils have thus far demonstrated mixed results. Insecticide treated nets were not associated
with decreased risk, but it is possible that respondents were not re-applying insecticide on old nets
depleted of the chemical repellents. Limitations to this study include small sample size, potential for
recall bias due to study design, and inability to generalize to populations not residing in informal
settlements. Additionally, this association does not demonstrate causality as coil use may be a general
marker of health seeking behavior. Mosquito coils may be useful low cost adjunct to insecticide treated
nets, but randomized controlled trials should be considered to prove efficacy.
126

PENNSYLVANIA POSTER FINALIST - RESEARCH Val Rakita, MD
Factors Affecting Physicians' Behaviors and Management of Cardiovascular Risk
Val Rakita, Nabeel Memon, Abul Kashem, Carol Homko, Nana Afari-Armah , Valaine Hewitt, William P.
Santamore, Alfred A. Bove
Introduction: Patients at increased risk for cardiovascular disease not only benefit from standard
pharmacotherapy, but also physician counseling regarding life-style behavioral changes such as weight
loss and exercise. This study sought to examine the patient factors that influence physicians' provision of
nutrition and exercise counseling among individuals at increased risk for CVD.
Methods: This was a secondary analysis of a telemedicine trial among an underserved inner-city and
rural population (n=388) with a 10% or greater CVD risk (Framingham 10 year risk score). Subjects were
followed for one year and were seen for quarterly assessments, which included evaluation of weight,
BP, lipid, and glucose status. At each of the four quarterly visits, subjects were asked if their physician
had discussed or made recommendations regarding life-style behaviors, specifically diet/weight loss and
exercise.
Results: The average age of subjects was 60.9 +/- 9.7 years and mean BMI was 31.6 +/- 7 kg/m2. CVD
risk decreased by 2.5% over the one year of follow-up (17.5 +-10.3% at baseline vs. 15 +/- 9.3% at 1 year,
p value

PENNSYLVANIA POSTER FINALIST - RESEARCH Julian Manuel Diaz Fraga, MD
Early Intravenous (IV) to Oral (PO) Azithromycin Conversion in Hospitalized Patients with Community
Acquired Pneumonia (CAP).
Julian Diaz-Fraga, MD; Archana Satyal-Chaudhary, MD; Andrew Crocker, MD; Shuchi Gulati, MD; Gaurav
Gulati, MD; Anup Subedee, MD; David George, MD.
Introduction: Many patients admitted with community-acquired pneumonia (CAP) continue to receive
IV antibiotics for longer than necessary. Early conversion from IV to PO route has been reported to
increase patient safety and comfort, reduce cost, and facilitate earlier discharge, without compromising
medical care. We developed an intervention strategy to decrease the time from IV to PO conversion of
azithromycin therapy for CAP in hospitalized patients by 20% over a 3 month period.
Methods: This resident-led quality improvement project was conducted in a 750-bed community
teaching hospital in which all medications are ordered online. We created a radio button option added
to electronic CAP order set to allow physicians to preauthorize pharmacists to convert IV to PO
azithromycin for patients meeting certain criteria. Hospitalist and resident staff received real time
feedback to reinforce education and address variation in practice patterns. Pharmacy developed a
system of rapid identification of candidates for antibiotic conversion. Pre- and post-intervention
measures included time to conversion from IV to PO antibiotic dosing, length of stay, rates of
readmission, death, transfer to a higher level of care, and reconversion to IV antibiotic therapy. Baseline
and final statistics were collected via electronic health record (EHR) chart review.
Results: The average time from IV to PO azithromycin conversion was decreased by more than 50% (1 ½
days) after our intervention. A direct cost savings was estimated to be $17,500 per year and nursing
time reduced by 19.4 days /year (estimate extra 10 minutes per IV administration.) There was no
statistically significant difference in the length of stay, rates of readmission, death, transfer to a higher
level of care, and reconversion to IV antibiotic therapy. Physician acceptance was excellent, and the
process has been extended to the COPD order set.
Conclusion: A simple change in process substantially reduces time from IV to PO azithromycin
conversion in hospitalized patients with CAP, without compromising medical care. The process reduces
cost and saves nursing time. In order to impact length of stay, the team will develop the current
program to standardize discharge criteria and define appropriate oral antibiotic choice in this era of
increased pneumococcal resistance to azithromycin.
128

PENNSYLVANIA POSTER FINALIST - RESEARCH Joy L Montes, MD
Why do Patients Bounce Back? Findings of Reasons for Readmission among Patients Age 65 and Older
in a Community Hospital
Joy L. Montes MD, Kaihong Mi MD, Shazia Nazir MD, David Livert PhD, Mahesh Krishnamurthy MD FACP
Introduction: Hospital readmissions have increased substantially over the past 30 years. Such an event
is not only an emotional burden to patients and their families, but is very costly as well. Because of these
implications, the recently passed health-care reform legislation aims at reducing readmissions and plans
to penalize both hospitals and physicians who have higher than average readmission rates.
Multiple factors that contribute to hospital readmissions have been cited in the literature. Identification
of these risk factors locally will allow us to target interventions that will prevent readmissions at our
hospital.
OBJECTIVES: To identify reasons for readmission of older patients in our hospital and to examine
whether there are clear factors associated with early versus late hospital readmissions. We
hypothesized that patients non- compliance is the major reason for all cause readmissions.
Methods: Data were analyzed on a random sample of patients aged 65 and older who were admitted to
our hospital between December 1, 2008 and December 30, 2009. The most likely reason for readmission
was identified. The list of reasons for readmissions was drawn upon those cited in similar readmission
studies.
Results: 198 patients were included in the study accounting for a total of 324 readmissions. Of these, 25
% were readmitted within 7 days and 75% were readmitted between 8 and 30 days post discharge.
Nearly three out of ten (30%) readmission episodes could be attributed to a health-care associated
infection. Two other frequent reasons for readmission were that the patient required skilled nursing
upon discharge but did not receive it (21%) and, that the patient was diagnosed with other chronic
diseases (19%). Contrary to our expectations, patient noncompliance accounted for roughly 1 out of 7
(14%) readmission episodes.
Patients who were readmitted because they required skilled nursing upon discharge (and did not receive
it) were significantly more likely to be readmitted later (24%) than earlier (13%). Patients who exhibited
poor health on discharge were significantly more likely to be admitted earlier (10%) than later (3%).
Conclusion: High readmission rates are an overall marker of a poor health care delivery system.
Therefore, we need to constantly monitor the reasons for readmissions in our patients. Based on our
findings, avoidance of readmission may be secured through interventions designed to prevent and
contain health-care associated infections and enhanced discharge planning. The involvement of all
stakeholders is required in order to reduce this problem, improve patient and physician satisfaction,
avoid penalties and possibly better reimbursement for both hospitals and physicians.
129

PENNSYLVANIA POSTER FINALIST - RESEARCH Chathur Acharya, MD
Concordance Between MRCP and ERCP for Biliary Stone Detection
Dr. Chathur Acharya, Yazan Roumani, Dr. Sudhir Narla, Dr. Ibrahim Ghobrial
Introduction: In the past 2-3 decades, Endoscopic Retrograde Cholangiopancreatography (ERCP) has
been the gold standard for diagnosing biliary ductal dilation and stones. ERCP, however, has its
drawbacks; it is technically challenging, is operator dependant and carries the risk of
pancreatitis. Magnetic Resonance Cholangiopancreatography (MRCP) provides an alternative noninvasive
imaging tool. An evolving concept is to limit ERCP to intervention only. However, it is our
observation that the results of MRCP and ERCP are frequently in disagreement. We set out to study the
level of agreement between these imaging modalities.
Methods: Using the of University of Pittsburgh (UPMC) system database, data of patients who
underwent MRCP’s followed by ERCP’s within a 30-day time period was collected. Data included the
presence and location of biliary stones, and the presence of biliary duct dilatation or stricture. The
duration between the imaging studies was documented. Level of agreement between the two tests was
examined using kappa statistics.
Results: A total of 110 MRCP and their subsequent ERCP reports were studied. 86 of the studies were
done within a week. We found a very little level of agreement between MRCP and subsequent ERCP’s.
For stone detection the Kappa statistic was 0.455 (p

PENNSYLVANIA POSTER FINALIST - RESEARCH Ravi K Sharma, MBBS
Tackling the Readmission Epidemic, A Resident Teaching Service Perspective
Ravi K Sharma Additional authors: Dhakarwal P, Violago J, Bhasin R, Akinfolarin A, Ghobrial I
Introduction: Hospital re-admissions are common and add a great burden to the cost and resources of
health care. Readmission rates will soon serve as a quality measure negatively impacting hospital and
physician reimbursement. Most of the current studies are on general admissions and do not provide
specific data applicable to populations served by resident teaching services.
It is important to analyze causes of hospital readmission, formulate an assessment tool to identify high
risk patients and areas of “optimum return” to channel our resources. This study will help develop
systematic approach to rectify the causes, recognize potential intervention and reassess the impact after
implementation.
Methods: Retrospective analysis of health records (H/P, Discharge summary, ER, nursing, progress notes
and office notes) at resident teaching services from August 2010 to May 2011. 204 readmissions within
30 days of discharge irrespective of discharge or readmission diagnoses were analyzed.
Results: Causes of readmissions were diverse: 28% patient factors (non-compliance, drug/alcohol use),
29% end stage illness (e.g. COPD, CHF, Cancer), 4% medication problem (cost, coverage, prescription
error), 3% premature discharge or early return from nursing home (3%), 3% inadequate instructions and
poor follow up (6%) or inappropriate discharge level of care (3%). Readmissions due to new diagnoses
were also accounted (21%).
Conclusion: Multiple factors contribute to readmissions hence it is not realistic to expect one single
solution. With 28% of readmissions due to lifestyle choices, insurer should develop patients’ incentives
to enhance compliance. With 21% of readmissions due to new diagnoses, punitive measures against
hospitals and physicians are unwarranted. Improving system based practices like collaborating drug
addiction programs with hospitals, enhancing interdisciplinary approach for comprehensive medical
reconciliation, reviewing medication formulary status and discharge instruction, assessing level of
discharge, ensuring appropriate follow up, early implementation of medical care guidelines and end of
life care are important to curb readmission rates.
131

PENNSYLVANIA POSTER FINALIST - RESEARCH Abhishek Biswas, MBBS
Comparison Between Transthoracic and Transesophageal Echo in the Detection of Vegetations in
Endocarditis Patients: A Retrospective Analysis
Abhishek Biswas, MBBS Additional authors: Misra S,Yassin M,Pinevich A
Introduction: Echocardiograms have served as a backbone of the diagnostic methodology for infective
endocarditis. Transthoracic echocardiogram (TTE) has been found to have a lower sensitivity for
detection of vegetations as compared to transesophageal echocardiogram (TEE) (85-95%). TEE is
routinely ordered in cases of suspected endocarditis. The AHA guidelines recommend TEE as the initial
test to rule out endocarditis in high risk individuals.Objectives of the study: This retrospective review
was a quality improvement study aimed at showing if there is any additional benefit from ordering TTE
prior to ordering TEE in high- risk patients with suspected endocarditis. The study also looked into the
cost analysis of ordering TTE prior to TEE.
Methods: A retrospective chart review treated at UPMC Mercy between May 2009 and June 2011 was
performed. Using standardized billing codes, patients were selected based on the following criteria: 1)
had a final diagnosis of endocarditis, 2) underwent both TTE and TEE and 3) had presence of a
vegetation on TEE.
Results: The review found 27 patients with endocarditis fulfilling the inclusion criteria. The results of this
study showed that TTE detected evidence of vegetations in only 29.6% of the patients included. Review
of literature showed that TEE has sensitivity around 90%. Sensitivity was especially low for detection of
vegetation on mitral (11%) and tricuspid (16.7%) valves. From a financial standpoint, the cost of TTE
could have been saved if TEE had been done as the initial diagnostic study.
Conclusion: In high-risk patients with suspected endocarditis, TEE should be ordered initially. TTE does
not add any beneficial information and is not cost-effective.
132

PENNSYLVANIA POSTER FINALIST - RESEARCH Leena Jalota, MD
Evidence for the Prevention of Ventilator Associated Pneumonia: Systematic Review and Metaanalysis
of Randomized Controlled Trials
Leena Jalota, MD
Introduction: Ventilator associated pneumonia (VAP) is associated with an increase in mortality in
critically ill patients and poses a significant economic burden on our health care system. Numerous
preventive strategies have been extensively investigated, yet, there is currently no comprehensive
review that systematically evaluated of all available evidence.Hence our objective is to provide clinicians
with a comprehensive, evidence-based overview that includes all published interventions for the
prevention of VAP.
Methods:
Data Sources: Published articles through June 2011 from Pubmed, EMBASE, CINAHL, ISI andthe
133
Cochrane Database, complemented with a hand-search of references. Ongoing trials were
identified using www.clinicaltrials.gov and authors contacted for relevant data.
Study Selection: Randomized controlled trials of critically ill adult patients requiring mechanical
ventilation and in whom pneumonia was a measured outcome.
Data Extraction: A total of 2073 publications were screened and 185 met predefined inclusion
criteria. Odds ratios with 95% confidence intervals (OR; 95% CI) were determined using RevMan
5.1.
Results:The following interventions – based on multiple studies and sorted according to their effect size
– significantly reduced the incidence of VAP: Weaning protocols for non-invasive ventilation (0.14; 0.07-
0.25), subglottic suctioning (0.34; 0.24-0.49), Rotational therapy (0.34; 0.23-0.52), selective
decontamination of the gut (0.37; 0.32-0.43), oral care with chlorhexidine (0.51; 0.35-0.75), aerosolized
antibiotics (0.52; 0.28-0.95), systemic antibiotics (0.56; 0.32-0.99) oral probiotic administration (0.59;
0.36-0.98, silver coated tubes (0.62; 0.43-0.88) and sucralfate as an alternative to H2-antagonists (0.77;
0.61-0.97). The following interventions – based on single studies only – were also statistically
significant: Antioxidant therapy (0.12; 0.03-0.49), chest physiotherapy (0.14; 0.03-0.70), oral care with
povidone-iodine (0.14; 0.04-0.58), trace element supplementation (0.15; 0.03-0.68), subglottic
decontamination (0.17; 0.05-0.56), and enteral versus parenteral nutrition (0.39; 0.18-0.85). All other
interventions failed statistical significance, including several commonly advocated interventions such as
semi recumbent positioning (0.4; 0.15-1.04), early tracheostomy (0.66; 0.31-1.38), and prone positioning
(0.82; 0.58-1.18).
Conclusion: There are various pharmacological and non-pharmacological interventions that reduce the
incidence of VAP. A common characteristic seems to be that all these interventions work around the
principle of reducing the micro-aspiration and the related bacterial load. Implementation of these
strategies into practice will definitely help in controlling the incidence of a seriously morbid and a life
threatening nosocomial infection.

PENNSYLVANIA POSTER FINALIST - RESEARCH Keyur K Mavani, MBBS
Empanelment – A Way to Improve Continuity of Care, Healthcare Quality and Patient Satisfaction
Keyur K Mavani, MBBS, Other authors: Nanavaty S. MD, Thomas L. MD, Sheth J. MD, Yellappa S. MD
Introduction: Physician-patient relationship, trust and faith in physician, patient safety and patient
satisfaction come from continuity of care. In our out-patient practice of more than 5000 patients, we
noticed that many patients were seen by different physicians, residents and extenders at each
visit. Patient satisfaction was worsening and complaints were increasing along with lack of continuity
leading to decline in quality, safety and communication. The quality of care, safety and patient
satisfactions are our goal at our practice. Our observation suggested that providing a systematic way to
allow patients to see their own resident and PCP will be the best way to manage these growing
concerns. As a result of long discussion to improve in these areas, we decided to do a quality
improvement project named as “Empanelment”.
Methods:
1. We cleaned patient registry and created a list of patients who were active in last 3 years. The
number came close to 5000.
2. Calculated supply of physicians and extenders according to their FTEs.
3. For the already established patients, we went into individual patient’s appointment history and
linked them with their preferred providers.
4. Assigned 350 patients to each resident. Panel sizes were adjusted for diabetes and Hypertension
maintaining age range.
5. Second option was provided as a backup for physicians, residents and extenders in the
“preferred provider form” – a document we created in our EMR.
6. Schedulers were trained to schedule according to this preferred provider form.
7. Entire process was made patient centered. Patient can change their provider if they are not
happy with the provider assigned to them.
8. Planned to review every 3 months with reports generated by out electronic medical record
system.
Results: The results in first 3 months after implementation are encouraging. The clinic is more
organized. Patients are more satisfied as they are seen by the same resident and physician during each
visit. The numbers of complaints regarding patient scheduling have decreased by 75%. Residents are
more proactive managing their own patients, taking the ownership and scheduling their appointment
with them, than before. Although it is a difficult task for schedulers, they are adapting to new system
steadily.
Conclusion: We strongly believe that the concept of empanelment will change the way medicine is
practiced, especially in residency programs, which potentially will improve resident education. In near
future ‘Empanelment’ will take the level of education to higher level and prepare the doctors in training
to provide better, safer and efficient care to their patients.
134

PENNSYLVANIA POSTER FINALIST - RESEARCH Ryan Arthur McConnell, MD
Improving the Quality of Care for Critically Ill Patients Immediately After Intubation
Faraz S. Ahmad, MD Ryan A. McConnell, MD Mitesh S. Patel, MD, MBA Barry D. Fuchs, MD Meeta
Prasad, MD, MSCE
Introduction: Post-intubation is a vulnerable time for critically ill patients in the medical intensive care
unit. Delayed monitoring and management of ventilation status and lack of communication amongst
interdisciplinary care team members can cause significant patient harm. The arterial blood gas (ABG) is
used to monitor physiologic response after intubation.
Outline of Problem: Morbidity and Mortality Review (M&M) at the Hospital of the University of
Pennsylvania identified two adverse events related to delayed monitoring of ventilation status in
recently intubated patients. Lack of protocols for patient care and provider communication were
identified among the root causes. Our objective was to evaluate the impact of a multidisciplinary Post-
Intubation Time Out process on the quality of care of mechanically ventilated patients.
Methods: Strategy for Change: A multidisciplinary Post-Intubation Time Out document was developed
for the care team to administer after each intubation. Nurses (RNs), respiratory therapists (RTs), and
physicians (MDs) were involved in document creation and each received education prior to
implementation. The Time Out includes a checklist of key tasks and assigns responsibilities to each
member to be completed within 1 hour.
Process of Gathering Information: Data were retrospectively collected on patients intubated prior to the
M&M and prospectively collected on patients intubated after Time Out implementation.
Key Measures for Improvement: Primary process measurements include time from intubation to ABG
result, proportion of patients with ABG resulted in less than 1 hour, and percentage of Time Outs with at
least an RN, RT, and MD participant.
Results: Analysis and Interpretation: Prior to Time Out implementation, mean time from intubation to
ABG result was 151.3 minutes, (95% Confidence Interval [95% CI]: 66.5-228.2). Proportion of patients
with ABG resulted in less than 1 hour was 27.3%. No guidelines exist for ventilation monitoring postintubation,
though it is known that carbon dioxide reaches steady state in approximately 15
minutes. Thus, a mean of 151.3 minutes represents a potentially dangerous delay in care.
Effects of Change: Amongst 36 patients intubated after implementation of the Time Out, 88.9% had an
RN, RT, and MD participant. Mean time from intubation to ABG result decreased to 76.3 minutes (95%
CI: 54.8-87.5). Proportion of patients with ABG resulted in less than 1 hour more than doubled to
63.9%.
Conclusion: The Post-Intubation Time Out process improved the coordination and timeliness of postintubation
patient care. The Time Out continues to be used to reach a target sample size of 60 patients
in each group, at which time evaluation for statistical significance will be conducted. If successful, the
Time Out will be expanded to other ICUs to demonstrate reproducibility in multiple settings.
135

PENNSYLVANIA POSTER FINALIST - RESEARCH Parit Mekaroonkamol, MD
When Bleeding Recurs, Should Colonoscopy be Repeated?
Parit Mekaroonkamol,MD; Kimberly Jegel Chaput,DO; Young Kwang Chae,MD; Michael Davis,MD;
Pojnicha Mekaroonkamol,MD; Sherry Pomerantz,Ph.D; Philip O. Katz,MD.
Introduction: While the intervals for repeating colonoscopy for colorectal cancer(CRC) screening or for
polyp surveillance are well described, there are no set guidelines for repeating a colonoscopy for other
indications such as recurrent lower gastrointestinal bleeding (LGIB) or abdominal pain. It is also not
known if repeating a colonoscopy for these indications is useful. This study aims to assess the yield of
repeat colonoscopy performed for the same indication other than CRC screening or polyp surveillance
within three years of the index procedure in producing changes in clinical management.
Methods: A retrospective review of patients who had more than one colonoscopy performed for the
same indication within three years at Albert Einstein Medical Center between January 1,2000 and
January 1,2010 was conducted. Exclusions included patients with repeat colonoscopies performed for
CRC screening/surveillance or poor bowel preparation. Clinical parameters including age, sex, race,
interval between procedures, indication of the procedure, presenting symptoms, severity of symptoms,
hemodynamic instability, duration between onset of symptoms and the procedure, change in
endoscopist, withdrawal time, location of colonic lesions and quality of bowel preparation were
analyzed with bivariate analysis and logistic regression analysis to examine correlation with clinically
significant change, defined as any change in management during or after the procedure.
Results: Among 19,772 colonoscopies performed during above mentioned period, 139 pairs of
colonoscopies met the inclusion criteria. The vast majority of repeat colonoscopies were for
LGIB(88.4%), changes in bowel habit(6.4%) and abdominal pain(5%). Among 139 eligible pairs of
colonoscopies, only repeat colonoscopies that were done for LGIB and abdominal pain produced
endoscopic findings that resulted in a change in management (27 out of 123 and 2 out of 7,
respectively). When looking at only recurrent LGIB cases, endoscopic findings included 8 new
hemorrhoid lesion(6.5%), 7 actively bleeding lesions requiring endoscopic interventions(5.7%), 7
previously undetected polyps(6 were smaller than 1 cm(4.9%) and 1 was larger than 1 cm(0.8%)), 3
radiation proctitis/colitis(2.43%), 1 rectal ulcer(0.8%), and 1 previously undetected cancer(0.8%). Of all
parameters analyzed, only the interval between procedures more than one year (1-2 and 2-3 years) was
associated with less likelihood of finding clinically significant change than 0-1 year(Odds Ratio(OR) 0.09;
95% Confidence Interval (CI) 0.01-0.74; p=0.025 and OR 0.26;95% CI 0.09-0.72, p=0.010 respectively).
Conclusion: The results of this study suggest that there may be clinical value of repeating a colonoscopy
for recurrent LGIB. However, the reasons for the increase in diagnostic yield in the first year after the
index procedure are unclear. Further prospective studies are warranted.
136

PENNSYLVANIA POSTER FINALIST - RESEARCH Eva Tseng, MD
Particulate Matter and Chronic Disease: Cohort Study from Taiwan
Eva Tseng, MD, MPH; Wen-Chao Ho, ScD; Meng-Hung Lin, MS; Pau-Chung Chen, MD, PhD; Hsien-Ho Lin,
MD, MPH, ScD
Introduction: Nearly 2 million premature deaths worldwide are attributed to air pollution which poses a
major environmental risk to health. A number of cohort studies from the United States and Europe have
shown that long-term exposure to fine particulate matter (PM 2.5) is an important predictor of mortality
for cardiopulmonary disease. However, few studies have examined the effects of PM 2.5 in the Asian
population. We examined the association of long-term exposure to PM2.5 with cardiovascular and
cerebrovascular (CVD) mortality in Taiwan.
Methods: In this prospective cohort study, we followed 13,276 subjects in 4 townships across Taiwan
from 1991-2009. Information on sociodemographic and behavioral factors and blood chemistry was
collected at baseline. Mean pollution levels for PM2.5 at the township level during 2000-2009 were
estimated by a combination of statistical and geospatial methods using recorded level of PM 2.5 (since
2005) and PM 10 (since 2000) from 67 monitoring stations in Taiwan. The underlying cause of death was
determined by ICD-9 and ICD-10 codes. We estimated the effects of air pollution CVD mortality using
Cox proportional-hazards regression modeling, while controlling for individual risk factors. Since the
baseline hazard of CVD mortality might vary in different regions (north/south), we further conducted a
stratified Cox regression analysis by region.
Results: During the 19-year follow-up, there were 286 deaths due to cardiovascular and/or
cerebrovascular causes (189 males and 97 females). In the unadjusted analysis, CVD mortality by
township was not significantly associated with air pollution (HR=1.07 for every 10ug/m3 increase in
PM2.5; 95% CI=0.96-1.20). The association remained non-significant (HR=1.02 for every 10ug/m3
increase in PM2.5; 95% CI=0.91-1.15) even after adjusting for individual-level risk factors (gender, age,
education, smoking, pack-years, alcohol, body mass index, triglyceride and cholesterol levels, diabetes,
hypertension, and glomerular filtration rate). In the stratified analysis by region, there was a stronger
association between PM 2.5 and CVD mortality in the multivariate-adjusted model (HR=1.21 for every
10ug/m3 increase in PM2.5; 95% CI=0.95-1.54). The effect of PM 2.5 was possibly modified by sex (p for
interaction: 0.066), with males being more susceptible than females. We did not find evidence of effect
modification by chronic disease status (p for interaction: 0.41).
Conclusion: This population-based cohort study from Taiwan provides some supporting evidence of a
positive association between CVD mortality with fine particulate air pollution when stratified by north
and south regions. However, most of the observed associations were not statistically significant; possibly
due to the small number of events and measurement error in PM 2.5 levels. The possibility that males
might be more vulnerable to the effects of PM 2.5 needs to be further investigated.
137

SAUDI ARABIA POSTER FINALIST - RESEARCH Mohammad Al Mansour
Non Prescribed Sale of Antibiotics in Riyadh, Saudi Arabia: A Cross Sectional Study.
Bin Abdulhak AA, Altannir MA, Almansor MA, Almohaya MS, Onazi AS, Marei MA, Aldossary OF, Obeidat
SA, Obeidat MA, Riaz MS, Tleyjeh IM. Internal Medicine Department, King Fahd Medical City, Aldabab Street,
Riyadh, 11525, Saudi Arabia.
Introduction: Antibiotics sales without medical prescriptions are increasingly recognized as sources of
antimicrobial misuse that can exacerbate the global burden of antibiotic resistance. We aimed to
determine the percentage of pharmacies who sell antibiotics without medical prescriptions, examining
the potential associated risks of such practice in Riyadh, Saudi Arabia, by simulation of different clinical
scenarios.
Methods: A cross sectional study of a quasi-random sample of pharmacies stratified by the five regions
of Riyadh. Each pharmacy was visited once by two investigators who simulated having a relative with a
specific clinical illness (sore throat, acute bronchitis, otitis media, acute sinusitis, diarrhea, and urinary
tract infection (UTI) in childbearing aged women).
RESULTS: A total of 327 pharmacies were visited. Antibiotics were dispensed without a medical
prescription in 244 (77.6%) of 327, of which 231 (95%) were dispensed without a patient request.
Simulated cases of sore throat and diarrhea resulted in an antibiotic being dispensed in (90%) of
encounters, followed by UTI (75%), acute bronchitis (73%), otitis media (51%) and acute sinusitis (40%).
Metronidazole (89%) and ciprofloxacin (86%) were commonly given for diarrhea and UTI, respectively,
whereas amoxicillin/clavulanate was dispensed (51%) for the other simulated cases. None of the
pharmacists asked about antibiotic allergy history or provided information about drug interactions. Only
23% asked about pregnancy status when dispensing antibiotics for UTI-simulated cases.
CONCLUSION: We observed that an antibiotic could be obtained in Riyadh without a medical
prescription or an evidence-based indication with associated potential clinical risks. Strict enforcement
and adherence to existing regulations are warranted
138

SAUDI ARABIA POSTER FINALIST - RESEARCH Arif Abdul Hak
The Role of Statins in Prevention and Treatment of Community Acquired Pneumonia: A
Systematic Review and Meta-analysis
Aref A. Bin Abdulhak, Abdur Rahman Khan, Muhammad Riaz, Mohamad A. Al-Tannir, Musa A. Garbati, ,
Patricia J. Erwin, Larry M Baddour, Imad M. Tleyjeh,
Background: Emerging epidemiological evidence suggests that statin use may reduce the risk of
community-acquired pneumonia (CAP) and its complications.
Purpose: To systematically review the association between statin use and the risk of CAP and related
mortality.
Data source: Ovid MEDLINE, EMBASE, ISI Web of Science, and Scopus from inception through December
2011 were searched for randomized trials, cohort and case-control studies.
Study selection: Two authors independently reviewed analytical studies that examined the role of
statins in CAP
Data extraction: Data about study characteristics, adjusted effect-estimates and quality characteristics
was extracted.
Data synthesis: Eighteen studies corresponding to 21 effect-estimates (eight and 13 of which addressed
the preventive and therapeutic roles of statins, respectively) were included. All studies were of good
methodological quality. Random-effects meta-analyses of adjusted effect-estimates were used. Statins
were associated with a lower risk of CAP, 0.84 (95% CI, 0.74-0.95), I2 = 90.5% and a lower short-term
mortality in patients with CAP, 0.68 (95% CI, 0.59-0.78), I2 = 75.7%. Meta-regression did not identify
sources of heterogeneity. A funnel plot suggested publication bias in the treatment group. A novel
regression method to adjust for publication bias resulted in an adjusted -estimate of 0.85 (95% CI, 0.77-
0.93). Sensitivity analyses using the rule-out approach showed that it is unlikely that the results were
due to an unmeasured confounder.
Limitations: Observational studies and between-study inconsistency
Conclusions: The results of a rigorously conducted systematic review and meta-analysis suggest that
statins have a beneficial effect in reducing risk and improving mortality of CAP
139

SAUDI ARABIA POSTER FINALIST - RESEARCH Zianab Al Duhailib
Glomerulonephritis with Crescents among Adult Saudi Patients-Outcome and its Predictors
Duhailib Z, Oudah N, Alsaad K, , Qurashi S Ghamdi G, Flaiw A , Hejaili F, , Farooqui M and Al Sayyari
Introduction: To investigate the clinical and pathological features, outcome and its predictors in
glomerulonephritis with crescents among adult patients
Method: This is a retrospective study of crescentic GN over a 9 years period. Histological features, renal
function at presentation and renal outcome among different etiological groups were compared at
baseline and end of follow up period.
Results: The mean age was 27.7 ± 9.9 years in the lupus nephritis (LN) group, and 46.9± 18 in the pauciimune
glomerulonephritis (PIGN) group (p=0.001). 49.3% were due to LN and 26.5% due to PIGN. 85.7%
had renal impairment at presentation (73.3% in LN and 100% in PIGN). Females accounted for 85.3 %,
76.5% and 36.2% in LN, PICN and ICGN respectively (p=0.025).
By the end of the follow up period of 26± 22.9 months, 25.8% of the patients needed dialysis (16.70% in
LN, 50% in PIGN and 25% in ICGN (p=0.05) while 21.7 % had nephrotic range proteinuria (16.7 %, 1%
and 33.3 % respectively (p=0.4).
Comparing LN, PIGN and ICGN using ANOVA, we found significant differences between groups in gender
(p =0.035), in % of sclerorsed glomeruli (SG) (p=0.012) and age (p=0.006).
Using multivariate analysis, we found the independent predictors for hemodialysis requirement and
renal prognosis to be SG, ATN, degree of Bowman membrane thickening and vasculopathy but not the
baseline proteinuria or SCR, gender or the number of glomeruli with crescents.
Conclusion: Almost half of our patients with CrGN were due to LN. Patients with PICN were older and
had worse prognosis. Predictors of renal death were SG and ATN. This could be explained by the higher
number of globally sclerorsed glomeruli in the PIGN group.
140

SOUTH CAROLINA POSTER FINALIST - RESEARCH Elmira Basaly, MD
An Analysis of House Officer Implementation of Standardized Hand-Off.
Elmira Basaly, MD Elizabeth Edwards, MD Rashmi Ganith, MD Alexis Lewis, MD Myron Kung, MD
Caroline Powell, MD
Introduction: The Institute of Medicine estimated that up to 98,000 deaths occur each year because of
preventable medical errors. Significant portion of medical errors arise from miscommunication during
transfer of care. In most residency programs, trainees manage transitions via verbal, written, or
combined methods of communication termed “hand-offs.” In 2003, the Accreditation Council for
Graduate Medical Education (ACGME) instituted a mandatory 80-hour work week to reduce medical
errors related to decisions made by exhausted residents. A consequence of work hour restrictions is that
patient care has become more fragmented with multiple requisite hand-offs. Despite the critical
importance of hand-offs, little research has examined the content, procedure, and effectiveness of this
process. Even less is known about how hand-offs should be conducted or how interventions might
improve the quality of hand-offs.
Methods: Our hypothesis was that implementation of a standardized hand-off would lead to improved
resident perception and quality of hand-off. We conducted a prospective cohort study of hand-off
perception pre and post implementation of a standardized process amongst 30 internal medicine
residents at Palmetto Health Richland between January to July 2011. A survey before and after the
implementation of a standardized hand off was distributed. Post-implementation data was compared to
pre-implementation data using a paired two-tailed t-test (p= 0.05) analysis of a composite score to
assess strength of effect. The survey contained 5 questions. Responses were ranked from 1 to 5. The
composite score included each question weighted equally with secondary outcomes (number of calls,
number of transfers or medical events) factored into the analysis.
Results: A standardized hand-off has been implemented within our residency program. We recommend
standardized hand-off to include updated information, anticipated events and guidance, with priority
given to sickest patients. Two questions, regarding unanticipated events and formal instruction had a
near acceptable p-value with our study.
Conclusion: Standardized hand-off is meant to improve quality of care ultimately leading to patient
safety and resident confidence in decision making. Our next phase is to study satisfaction and
quantitative analysis of house-officer preception of standardized hand-off.
141

SOUTH CAROLINA POSTER FINALIST - RESEARCH Fatima Cody Stanford, MD,
MPH
Factors that Influence Confidence in Patient Counseling on Physical Activity in Attending Physicians,
Resident and Fellow Physicians, and Medical Students in the United States
Fatima Cody Stanford, MD, MPH; Martin W. Durkin, MD; Caroline Keller Powell, MD, MSCR; Mary Beth
Poston, MD, MSCR; James Rast Stallworth, MD, and Steven N. Blair, PED
Introduction: In 2008, the US Department of Health and Human Services (USDHHS) released its first
national guidelines for physical activity. More than 80% of adults do not meet the guidelines for both
aerobic and muscle-strengthening activities. Very few studies have been performed to determine the
level of physical activity in physicians and medical students. There is evidence that the level of physical
activity of physicians may be correlated directly with physician counseling pattern about this
behavior. The objective of our study was to determine which factors are associated with a higher
likelihood of confidence in counseling patients about physical activity.
Methods: We established an online exercise survey targeted at attending physicians, resident and fellow
physicians, and medical students to determine their current level of physical activity and confidence in
counseling patients about physical activity. Their level of physical activity was compared with the 2008
physical activity guidelines of the USDHHS. The survey was generated using the short form of the
International Physical Activity Questionnaire (IPAQ). The period of data collection was approximately 8
months (June 2009- January 2010). The results were analyzed with logistic regression and stratification
of two by two tables using the Mantel-Haenszel chi-squared test.
Results: A total of 1949 individuals responded to the survey; 1751 were included in this analysis (566
attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students). The
odds of an individual who met the USDHHS guidelines for vigorous activity being confident in exercise
counseling were 2.23 times those of an individual who did not meet the USDHHS vigorous activity
guidelines after adjusting for BMI (p

TENNESSEE POSTER FINALIST - RESEARCH Muhammad U Khan, MBBS
Acute Stressor States: Cation Dyshomeostasis, Prolonged Myocardial Repolarization with Cardiac
Arrhythmias And Necrosis
Muhammad U Khan, MBBS Other Authors: Atta Ur-Rehman Shahbaz, MBBS; Heena Khalid, MBBS; Karl T.
Weber MD.
Introduction: Acute stressor states involves neurohormonal activation with elevations in plasma
catecholamines that promote translocation of circulating cations into soft tissues. In the heart, the
resultant dyshomeostasis of extra- and intracellular cations is accompanied by the prolongation of
myocardial repolarization with a greater propensity for atrial and ventricular arrhythmias and
nonischemic cardiomyocyte necrosis. Herein, we studied serum electrolytes and troponin-I (trop-I),
corrected QT interval (QTc) from the ECG, and the appearance of arrhythmias in acutely ill patients
hospitalized in a medical intensive care unit (MICU) to elucidate their potential pathophysiologic
correlations.
Methods: A retrospective chart review of 200 consecutive patients (58±1 yrs; 106 females) admitted to
a MICU from April to August 2010, with acute stressors, such as sepsis, pulmonary embolus, acute
lymphocytic leukemia, intracranial hemorrhage, subdural hematoma, or diabetic ketoacidosis, and who
did not have previously documented arrhythmia or chronic renal failure (serum creatinine >1.4
mg/dL). Total serum [Ca2+] and ionized [Ca2+]o, K+, Mg2+, and trop-I, together with QTc (ms) and
cardiac rhythm, obtained within 12–48 h of admission, were noted.
Results: Hypocalcemia was present in 70% and ionized hypocalcemia in 70%; K+

TENNESSEE POSTER FINALIST - RESEARCH Muhammad U Khan, MBBS
Idiopathic Intracranial Hypertension Associated with Hypocalcemia and Aldosteronism: A Case Series
Muhammad U Khan, MBBS Heena Khalid, MBBS; Karl T. Weber, MD.
Introduction: Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a clinical
syndrome whose symptoms and signs include headache, with or without visual disturbances and field
defects, together with papilledema. The pathogenic origins of IIH remain uncertain. In our previous
report (J Investig Med 2011;59:402), we summarized 10 patients with IIH having primary or secondary
aldosteronism. Aldosteronism is a known cause of hypocalcemia which has been reported in some
cases of IIH. To explore the pathomechanistic basis of this association we studied 15 reported cases
with IIH and hypocalcemia of various etiologies.
Methods: We conducted a retrospective study to summarize 15 patients with IIH and hypocalcemia
which had been reported in the literature.
Results: The female:male ratio was 9:6. Patients were 12±3 yrs old at the time when the diagnosis of
hypocalcemia was made, whereas they were 16±3 yrs old when IIH was diagnosed. Hypocalcemia was
related to vitamin D deficiency in 11, hypoparathyroidism in 2, pseudohypoparathyroidism in 1 and an
inherited renotubular defect in 1. All patients exhibited clinical symptoms related to hypocalcemia
before development of symptoms of IIH. Plasma calcium levels 1.38±0.16 mM were significantly
decreased (normal, 2.1–2.6 mM) as were plasma magnesium levels (0.41±0.13 mM; normal, 0.6–1.1
mM). Symptoms of IIH were controlled by: polynutrient dietary supplementation in 10, lone vitamin D
and calcium supplementation in 4, and cessation of thiazide diuretic and replacement of magnesium and
calcium in 1.
Conclusion: An association between IIH with severe symptomatic hypocalcemia has been reported in
young patients while an association between IIH with primary aldosteronism occurs in hypertensive
middle-age women, whereas normotensive girls having an inherited renotubular defect can have IIH
with secondary aldosteronism. Patients with IIH therefore should be evaluated for both hypocalcemia
and aldosteronism. Replacement of calcium and magnesium, together with the use of calcium and
magnesium-conserving diuretics, offers effective treatment for both hypocalcemia and IIH.
144

TENNESSEE POSTER FINALIST - RESEARCH Owaisur Rahman, MD
Point of Care Testing: Efficient, but Accurate?
Rahman, Owaisur MD (Associate), Rasnake, Mark MD (FACP)
Introduction: Point of care testing (POCT) is utilized more frequently in emergency departments (EDs)
across the United States and has had a profound impact on the practice of emergency medicine. POCT is
defined as medical testing at or near the site of patient care, bringing the test conveniently to the
patient. Our institution recently instituted POCT in its ED. Following implementation, a difference
between the POCT labs and standard labs was noted by internal medicine residents. This observation
resulted in a resident-led quality improvement project which looked at the implementation of these
POCT labs and how well they correlated with standard lab testing.
Methods: The patient population consisted of adult patients with POCT International Normalized Ratio
(i-INR) drawn and admitted to our facility through the ED over a two month period. Of these patients,
only those who also had an INR value drawn by standard lab methods within three hours of the initial i-
INR were included. Any patients who had interventions performed that would alter their INR value were
excluded. The data was then analyzed for correlation between i-INR and standard INR values.
Results: Fifteen patients who had an i-INR and a subsequent standard INR value drawn within three
hours of the initial test were included in this Quality Improvement study. The average difference
between the two values was .88 with a range of approximately 0 to 2.86. Further analysis of the two
data sets did not show a statistically significant correlation between the values. The coefficient of
correlation, r, was found to be .425 and the coefficient of determination, r 2 , was determined to be .181.
Given the poor correlation between the i-INR values and standard INR values, a department wide review
of the POCT process was initiated. This review revealed several problems with the implementation of
the POCT INR to include inconsistent use of fingerstick-only blood as required by manufacturer
specifications. Additionally, testing was not always performed immediately at the bedside, delaying
processing of some specimens for hours. Retraining staff on the importance of strict adherence to
manufacturer protocol for POCT was initiated. Follow up parallel testing of 21 sequential specimens
obtained in the ED showed significant improvements in accuracy with an r of .998 and an r 2 of .997.
Conclusion: Our findings demonstrate the importance of strict adherence to manufacturer protocols for
POCT technology. Implementation of any new technology has the potential to produce errors as staff
adapt to new procedures. Furthermore, our findings demonstrate the critical role medicine residents
play in identifying and preventing system errors in healthcare.
145

TEXAS POSTER FINALIST - RESEARCH Farshad Forouzandeh, MD
Utility Of Non-contrast Cardiac Computed Tomography In Predicting Coronary Events (Chapter
Winning Abstract)
Farshad Forouzandeh, MD, PhD; Su M. Chang , MD; Kamil Muhyieddeen, MD; Rasheed R Zaid, MD;
Alejandro R Trevino, MD; Jiaqiong Xu, PhD; Faisal Nabi, MD; John J. Mahmarian, MD.
Introduction: Non-contrast Cardiac Computed Tomography (NCCT) allows for calculation of coronary
artery calcium score (CACS) and measurement of epicardial adipose tissue and intra-thoracic fat
volumes (EATv and ITFv). The aim of this study was to evaluate the value of these measurements in
predicting coronary events (CEs) in compare to clinically derived cardiac risk stratification tools such as
Framingham Risk Score (FRS).
Methods: 760 consecutive symptomatic patients without known coronary disease underwent NCCT and
were followed up to 5 years (median 3.3 years) for CEs (cardiac death, non fatal MI, and acute coronary
syndrome with >70% coronary artery stenosis). The mean age was 54.4 ±13.7 years, 60 % were female,
15% were diabetics, mean body mass index (BMI) of 30.6 kg/m 2 and mean FRS of 8.2. The ITFv and EATv
were calculated with semi-automated method. Fat tissues were automatically recognized on CT scans by
threshold between -40 and-200 Hounsfield units.
Results: Compared to 715 event-free patients, the 45 patients who had CEs were older (64.8 vs 53.7 y/o
p400. The area under the curve from ROC analyses showed trends to improve CE
prediction when fat volume was added to FRS, BMI and log (CACS+1) (0.839 for EATv>125ml, 0.843 for
ITFv>250ml vs. 0.828, p=0.14 and 0.11 respectively). On the other hand, CACS significantly improved the
prediction when added to FRS and BMI (0.828 vs 0.724 p=0.001).
Conclusion: Symptomatic patients with CEs had larger ITFv and EATv and higher CACS. Although both
EATv and ITFv provided some incremental value over clinical information, CACS remained the strongest
predictor of outcome.
146

TEXAS POSTER FINALIST - RESEARCH Gurjot Kaur Basra, MBBS
Effects of Fluvastatin on Pro-inflammatory and Pro-thrombotic Markers in Antiphospholipid Antibody
Positive Patients: Results from a Prospective Pilot Study
Gurjot Kaur Basra, Vijaya L. Murthy, Doruk Erkan, Praveen Jajoria, Rohan Willis, ShraddhaJatwani JoAnn
Vega, Giuseppe Barilaro, Elizabeth Hsu, Laura Aline Martinez-Martinez, Elizabeth Papalardo, Emilio B.
Gonzalez, Prashanth R. Sunkureddi and Silvia S
Introduction: Purpose: The purpose of this pilot study was to examine the effects of fluvastatin on proinflammatory
and pro-thrombotic biomarkers in persistently aPL-positive patients
Methods: Persistently aPL-positive patients received fluvastatin 40 mg daily for 3 months (m). At 3m,
patients were instructed to stop fluvastatin and they were followed for another 3m. Persistent aPL
positivity was defined as IgG/M aCL = 40U, IgG/M aß2GPI = 20U, and/or positive LA test on =2 occasions
at least 12w apart. Selected exclusion criteria were pregnancy, statin use, prednisone >10 mg/day, and
immunosuppressive use (except hydroxychloroquine) at the time of the screening. Serum samples were
collected at baseline and monthly thereafter for 6m. IFNa2, IL1ß, IL6, IL8, IP10, MCP1, TNFa, VEGF, and
sCD40L levels were determined by the MILLIPLEXMAP human cytokine/chemokine assay (Millipore,
Billerica, MA). Plasma samples were used to detect soluble tissue factor (sTF) using a chromogenic assay.
CRP was evaluated by a nephelometric assay. aCL, aß2GPI, soluble ICAM-1, VCAM-1, and E-selectin were
evaluated by ELISA. For the purpose of this preliminary analysis of baseline, 1m, 2m, and 3m samples,
we: a) compared baseline biomarker levels of patients with serum samples from 30 healthy age/sexmatched
controls (Kruskal-Wallis test); and b) analyzed the change in biomarker levels of patients
between baseline and 1-3m samples (Spearman test).
Results:When we compared the baseline samples of 41 aPL-positive patients (74% female; mean age: 42
± 25; Primary APS: 18; asymptomatic aPL positivity with no SLE:9; APS with SLE: 7; and asymptomatic
aPL positivity with SLE:7) with controls, we found that the levels of IL6 (38 vs 0.7 pg/ml), VEGF (225 vs
114 pg/ml), IP10 (584 vs 107 pg/ml); sCD40L (2477 vs 24.7 pg/ml), INFa2 (213 vs 16 pg/ml), IL1ß (4.7 vs
0.4 pg/ml), TNFa 30 vs 0.5 pg/ml), and sTF (134 vs 13 pg/ml) were significantly elevated, but not of MCP-
1, IL8 or CRP. Based on the analysis of the available follow-up samples, fluvastatin significantly reduced
IL6, IL1ß, TNFa, sTF, sICAM-1, sVCAM, and sE-sel levels within 30-90 days of treatment.
Conclusion: Conclusions: Based on the preliminary analysis of our ongoing pilot study, fluvastatin 40 mg
daily for 3 months significantly reduced the pro-inflammatory and prothrombotic biomarkers in
persistently aPL-positive patients with or without SLE. These findings: a) underscore the importance of
identifying aPL-related disease biomarkers; and b) provide further support for the potential beneficial
effects of statins in aPL-positive patients justifying future controlled clinical studies.
147

TEXAS POSTER FINALIST - RESEARCH Samir J Patel, MD
Effect of Omalizumab on Health Care Utilization in Severe Asthmatics
Samir J Patel, MD
Introduction: Poorly controlled asthma is associated with increased health care
utilization. Omalizumab, a monoclonal antibody which blocks IgE, is recommended as an add-on
therapy for patients with moderate-to-severe persistent allergy-related asthma with inadequate
control. Patients require subcutaneous injections every two to four weeks when receiving omalizumab
therapy. While studies have shown reduced exacerbations, need for corticosteroids, and improved
symptom control with use of omalizumab, no study has specifically looked at the effect on healthcare
utilization.
Methods: We performed a retrospective, before-and-after study of adults receiving omalizumab for
asthma at six military tertiary care centers. Data was obtained through review of electronic medical
records of identified patients. Total health care visits, asthma-related health care visits, ER visits and
hospitalizations, and doses of oral steroids were assessed in the year prior to and year after starting
omalizumab therapy.
Results: Twenty-six patients were included in the analysis including 9 males (35%) and 17 females
(65%). There was a statistically significant increase in the mean number of total clinic visits, increasing
from 21.5 to 37.4 in the years prior to and after initiation of omalizumab respectively (p=0.003). There
was also a significant increase in the mean number asthma-related clinic visits, increasing from 10.3 to
21.0 (p

TEXAS POSTER FINALIST - RESEARCH Alejandro Velasco, MD
Female Gender and Low Body Mass Index May Predict a Difficult Radial Arterial Access
Alejandro Velasco MD, Chikako Ono MD, Patrick Tarwater PhD, Kenneth Nugent MD, Ashwani Kumar
MD
Introduction: Radial percutaneous coronary interventions have a lower bleeding rate and shorter time
to recovery than the femoral access. However, small arterial diameters requiring large sheaths can make
complex procedures difficult. No studies in the American population have validated the routine use of
5Fr sheaths. The identification of subjects with smaller arterial diameters may be beneficial for planning
cardiac interventions and prevent complications. This study assessed the diameter of the radial artery in
the American population, analyzed the factors affecting it, and assessed the feasibility of using larger
sheaths for radial interventions.
Methods: The right radial arterial diameters were measured using an ultrasound technique in 100 adult
volunteers at our institution. Diameters were measured 1 to 2 cm proximal to the radial styloid process.
A horizontal and vertical diameter was obtained in each radial artery and an average of both values was
considered as "average diameter". A logistic regression analysis was performed to identify factors
associated with a diameter smaller than 5Fr.
Results: The mean age of subjects was 35 years, 40% subjects were male and the mean body mass index
(BMI) was 27. The mean right average diameter for our entire population was 2.22 ± 0.35 cm. The
diameters ranged from 1.45 to 3.0 cm. The mean right diameter for males was larger (2.42 ± 0.33 cm)
compared to females (2.08 +/- 0.29 cm) (p value

USAF POSTER FINALIST - RESEARCH CPT KELVIN BUSH, MC, USAF
Efficacy of pioglitazone on viral kinetics, cytokines, and innate immunity in a group of insulin resistant
treatment naïve, genotype 1, chronic hepatitis c patients
Kelvin Bush CPT, MC, USAF (Associate), LTC Stephen A. Harrison, MD (FACP), Karol Barstow, RN,Prashant
Pandya, MD,Michael Charlton, MD
Introduction: Hepatitis C Virus (HCV) infection is an important cause of chronic liver disease, cirrhosis
and hepatocellular carcinoma worldwide. Several approaches have been used to predict the disease
progression and therapeutic response in chronic hepatitis (CHC) patients. Insulin resistance (IR), a
condition that precedes the development of type 2 diabetes (T2D), has been negatively implicated in
disease progression and response to antiviral therapy. IR reduces the response to interferon alfa-based
therapy of CHC patients by theoretically blocking interferon intracellular signaling. The use of
pioglitazone in addition to combination antiviral therapy has been shown to increase RVR and SVR in
non-genotype 1 patients. In this prospective study our goals were to 1)evaluate the effects of
pioglitazone on viral kinetics produced by a single dose of peginterferon alfa-2b, 2) to assess the impact
of pioglitazone on inflammatory cytokine mileu, and 3) to demonstrate pioglitazone induced changes in
intrahepatic gene expression profiles in insulin resistant, treatment naïve, genotype 1 CHC patients.
Methods: We performed a multicenter, prospective, randomized cohort study on insulin resistant,
treatment naïve, genotype 1, CHC patients (n=16). All study subjects received 1.5mcg/kg peginterferon
alfa-2b at days 0 and 97. The treatment group (n=10) received 90 days of pioglitazone 45mg. Liver
biopsy was done before and after treatment with pioglitazone (n=4). Viral load measurements were
obtained at 0, 6, 10, 24 hours, and day 2, 5, 7 following each injection. Gene expression profiles were
performed on liver samples obtained.
Results: No significant differences in viral kinetics between treatment groups (p=0.18) were found.
Measured serum cytokines were not significantly altered with pioglitazone treatment. Pre and post
differences in nitric oxide signaling apoptosis (p=0.002), leptin activity on JAK/STAT and MAPK cascades
(p=0.009), anti-apoptotic action of nuclear ESR1/ESR2 (p=0.009), and nine other gene expressions were
demonstrated.
Conclusion: The addition of pioglitazone to peginterferon alfa-2b did not improve viral kinetics in
treatment naïve, insulin resistant, genotype 1, CHC patients in comparison to peginterferon alfa-2b
alone. However, several genes involved with interferon intracellular signaling were significantly
upregulated with pioglitazone. Further studies are warranted to better understand the relationship
between IR and interferon signaling as it relates to CHC.
150

US ARMY POSTER FINALIST - RESEARCH CPT HILLARY THOMAS, MC USA
Effects of Illicit Drug use on Clinical Outcome of Heart Failure
Capt Ryan C Stoner, MD
Introduction: Illicit drug use is a known etiology for cardiomyopathy. However, prior studies evaluating
decompensated heart failure in illicit drug users have focused primarily on stimulant use and short term
follow-up; thus, a relationship between illicit drug use and long-term clinical outcomes is not well
described. The goal of our study was to describe characteristics of heart failure patients who used illicit
drugs, and to determine the effects of illicit drug use on clinical outcomes such as in-hospital mortality
and hospital readmission for heart failure.
Methods: We reviewed data collected for The Joint Commission in patients admitted with heart failure
at a university hospital serving an indigent high-risk population in Louisiana during the period from June
2003 to September 2004. Patients were divided into 2 groups: illicit drug use and no illicit drug use
groups based on self-reported use and positive laboratory results. Outcome measures were in-hospital
mortality, heart failure readmission rate, time to readmission for heart failure, and average brain
natriuretic peptide (BNP) and troponin levels throughout the follow-up period.
Results: Of 646 reviewed records, 542, representing 357 patients, were included in the analysis. There
were 53 patients in the illicit drug use and 304 in the no illicit drug use group. Mean (standard deviation)
of follow up period was 2.39 (1.6) years. Kaplan-Meier log-rank analysis demonstrated that illicit drug
use was associated with shorter time to readmission for heart failure (p< 0.0001, HR 3.8, 95% CI 2.3-
10.7); Multiple linear regression analysis identified illicit illicit drug use as an independent variable for
heart failure readmission rate (parameter estimate = 0.71; p=0.0001). We found no significant
difference in in-hospital mortality (p= 0.42), average troponin-I levels (p=0.4), or higher average BNP
levels (p= 0.36).
Conclusion: This study demonstrated that illicit drug use was associated with higher heart failure
readmission rates and decreased time to readmission for heart failure. In the era of the patientcentered
care, this study provides a mandate for increased community-based initiatives to mitigate the
problem of illicit drug use among indigent populations and improve appropriate utilization of limited
medical resources.
151

US ARMY POSTER FINALIST - RESEARCH CPT Sherrell T Lam, MD
Improving Tdap Coverage in a Military Beneficiary Population
Sherrell Lam, MD (Associate), Susan George, MD (Member), Susan Dunlow, MD, Michael Nelson, MD,
Joshua D. Hartzell, MD, FACP (Member). Internal Medicine, Walter Reed National Military Medical
Center, Bethesda, MD.
Introduction: Pertussis, a vaccine-preventable illness, has had a resurgence in the past several years. In
2009 alone, there were 16,858 cases and 12 deaths due to pertussis in the United States. Adults with
waning immunity are at risk of developing disease and then transferring it to unvaccinated infants.
Women of child-bearing age and adults with expected infant contact are an important potential source
of infection. Recent infant deaths and outbreaks led to new Tdap vaccine recommendations in 2010,
expanding coverage to include adults older than 65 who may have infant contact, and considering it in
all adults over 65. Time limitations were removed, allowing for administration of Tdap regardless of
when the last tetanus- or diphtheria-containing vaccination was given. Despite these changes,
vaccination rates remain strikingly low. A performance improvement (PI) project was developed to
improve Tdap coverage at Walter Reed National Military Medical Center in an effort to decrease
morbidity and mortality from pertussis.
Methods: The PI project targeted the high risk population of women of child-bearing age and other
adult females. Women seen in the Gynecology Clinic had their electronic medical record (EMR) screened
for Tdap as part of a routine vital signs assessment. Those eligible for vaccination were given a handout
with instructions on how to get the Tdap administered in the Immunization Clinic. Data was collected
from December 2010 to April 2011, and vaccination rates were determined one month before and after
the start of the PI project. Vaccination was considered a result of the intervention if it was received
within one month of the appointment.
Results: There were 1421 visits prior, and 881 following the PI project. Only 13% of all patients had a
documented Tdap at any time point. Following the intervention, vaccination rates increased from 0.38%
to 6.5% and patients were 19 times (95% CI: 7%-47%, P

USAF POSTER FINALIST - RESEARCH John Paul Magulick, Jr MD
Statins Effects on the Incidence of Infection
John Magulick, Capt, USAF, MC (Associate), Christopher Frei, PharmD Sayed Ali, MD (Member), Ishak
Mansi, MD (FACP)
Introduction: Despite their cardiovascular benefits, the effects of statin therapy on the incidence and
severity of infection remain unclear. While some observational studies suggest that statins protect
against infections and improve clinical outcomes, other studies suggest an opposite or no effect. Some
investigators suggest the studies that demonstrated improved outcomes in statin users are attributable
to “healthy user bias,” and statin use may be a surrogate marker for better patient care. Our objective
was to further investigate the incidence of infection in statin users compared to non-users within the
same healthcare system.
Methods: A retrospective cohort study of all patients in the San Antonio military multi-market was
performed from 1 October 2003 through 5 March 2010. Inpatient and outpatient ICD-9 codes were
compared between statin users and non-users. Statin users were defined as patients who received a
statin for at least 3 months between 1 October 2003 and 30 September 2004. Statin non-users were
defined as patients who did not receive a statin within the study period. The incidence of all infections
[ICD-codes: 001-139 (all infections); 795.3 (non-specific positive culture); and 795.5 ( positive PPD)] as
well as subtypes of infection (bacterial, viral, fungal and parasitic) were compared using multivariate
regression analysis between the two groups.
Results: Of 92,360 identified beneficiaries, 12,980 were statin users and 45,997 were non-users. After
adjustment for age, gender and the Charlson comorbidity index, there was no difference in the
incidence of infections between the two groups in the outpatient setting (odds ratio (OR): 0.98; 95%-CI:
0.92-1.05). However, the incidence of infection in hospitalized patients was lower in statin users
compared to non-users (OR: 0.58; 95%-CI: 0.37-0.90). Analysis of infection subtypes in the outpatient
setting revealed no significant difference in the incidence of bacterial (OR: 0.98; 95%-CI: 0.92-1.05), viral
(OR: 0.91; 95%-CI: 0.79-1.04), or fungal and parasitic (OR: 1.0; 95%-CI: 0.93-1.07) infections.
Conclusion: Statin use was associated with a lower incidence of infection in hospitalized patients, but
not in the outpatient setting. Furthermore, statin use was not associated with a difference in incidence
of bacterial, viral or fungal and parasitic infections in the outpatient setting.
153

US NAVY POSTER FINALIST - RESEARCH Brent Wallace Lacey, MD
Trans-Rectal Ultrasound-Guided Prostate (TRUSP) Biopsy
LT Brent W. Lacey, M.D. LCDR Christopher Duplessis, M.D. CAPT Mary Bavaro, M.D.
Introduction: Trans-rectal ultrasound-guided prostate (TRUSP) biopsy is one of the most common
urologic procedures performed in the United States. While infection risk is historically small (

VERMONT POSTER FINALIST - RESEARCH Justin M Stinnett-Donnelly, MD
Dermatology Clinic Time Motion Study and Monte Carlo Method Simulation to Optimize Clinic
Justin M Stinnett-Donnelly, MD, Stephanie Mariorenzi, Abigail Trutor, MBA
Introduction: Montecarlo simulation is a useful tool to evaluate hypothesis for optimizing clinic
schedules. No single schedule optimized efficiency parameters of both MD’s and patients. Decreasing
no-show rates has a paradoxical effect of increasing throughput while worsening schedule
performance. This is due to no-shows allowing random catch up during the day.
Methods: Time and motion analysis was conducted in June 2011. 56 half day clinics, 9 physicians
observed with 550 patient encounters. Timestamps were taken in the following order: a) medical
assistant (MA) and patient enter room, b) MA leaves room c) resident enters room (if resident available)
d) resident leaves room e) physician (MD) enters room f) MD exits room. No show and same day
cancelations were recorded. All observations were attained outside the exam room for patient
confidentiality. The mean time MA and MD spend with the patient by appointment length were
calculated.
Montecarlo clinic simulation was conducted using the data from the time motion analysis and estimate
of patient waiting room arrival characteristics. With this computer algorithm two different analyses
were undertaken: 1) Eight different morning schedules were evaluated with 4 fifteen and thirty minute
appointment slots each. The iterative model ran 10K times and the mean waiting time of the patient,
MA and MD was recorded for each step in the visit. The schedule which minimized patient waiting and
clinic end times was considered most efficient. The second analysis 2) evaluated the effect of no show
rates on schedule efficiency. The most efficient schedule was run 10K times varying no show rates from
0% to 12%. Efficiency was again defined as minimum patient wait times and end time of AM clinic.
Results: Mean (StDev) MA time for 15 and 30 minute appointments was 4.34(6.07) and 4.62(2.92)
minutes respectively. MD time with patient was 14.16(8.56) and 18.92(11.19). No Show appointments
were 11.64% of appointments. Under Montecarlo simulation mean wait in waiting room varied from
[0.8-1.9] minutes, wait in exam room was [2.6-3.4] minutes and mean time that clinic ended ranged
[11:58am-12:13pm]. No show variation resulted in an inverse relationship to patient weight times,
increasing patient exam room wait from 2.8 to 3.4 minutes and clinic end from 12:00 to 12:05pm.
Conclusion: Montecarlo simulation is a useful tool to evaluate hypothesis for optimizing clinic
schedules. No single schedule optimized efficiency parameters of both MD’s and patients. Decreasing
no-show rates has a paradoxical effect of increasing throughput while worsening schedule
performance. This is due to no-shows allowing random catch up during the day.
155

VIRGINIA POSTER FINALIST - RESEARCH Armin Rashidi, MD
Fresh Frozen Plasma Dosing For Warfarin Reversal: A Handy Formula
1. Armin Rashidi, MD: Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 2.
H. Raymond Tahhan, MD: Departments of Pathology and Internal Medicine, Eastern Virginia Medical
School, Norfolk, VA
Introduction: Fresh frozen plasma (FFP) administration is the most common method of warfarin
reversal. Currently, FFP dosing is not evidence-based and different societies propose different
guidelines. The purpose of the present study is to derive an easy-to-use formula in the form of DeltaINR
(i.e. PreINR – PostINR) = a x preINR + b, where a and b are constants, postINR is the INR after
administration of one unit of FFP, and preINR is the INR before FFP administration.
Methods: In a retrospective study (March 2009-March 2011), we review the data of all patients for
whom a total of 13,000 units of FFP has been released by the transfusion service in our institution. We
exclude patients with disseminated intravascular coagulation or liver disease, pregnant women, and
those who received recombinant factor VII or prothrombin complex concentrate. We use multivariate
regression for analysis, in which DeltaINR is the outcome variable and preINR is the main predictor.
Potential covariates in the model are age, sex, ideal body weight, whether or not vitamin K was
administered, and the timing of postINR relative to the time of FFP administration. We first find the
formula for the subset of patients that received only one unit of FFP. Next, we apply the formula from
the previous step, in a stepwise manner, to the subset that received 2, 3, 4, or 5 units of FFP. Finally,
predicted values of DeltaINR are compared with actual values.
Results: To date, we have reviewed 5,715 cases, of which 769 have met the inclusion criteria. The best
estimate for DeltaINR after one unit of FFP (n = 270) is 0.6 x preINR - 0.7 (R 2 =83%, p < 0.001). Including
additional variables in the model does not increase the predictive power of the model. Applying the
model to the subset who received two units of FFP (n = 377) reveals a strong correlation between
predicted and actual values of DeltaINR (R 2 =92%, p < 0.001).
Conclusion: Our formula provides an easy method to calculate how many units of FFP are required to
reverse INR to the desired level. It is also the most accurate formula available for this purpose and may
become the standard of care.
156

WEST VIRGINIA POSTER FINALIST - RESEARCH William Aaron Hood, DO
Proton Pump Inhibitor use in a Large Outpatient Clinic Population
William Hood DO Alicia Warnock DO Aditi Girme MD Nelson Smith DO Brandon Robinson DO Brittain
McJunkin MD FACP
Introduction: Proton pump inhibitors (PPIs) have replaced histamine-2 receptor antagonists (H2RAs) as
first line therapy for gastroesophageal reflux disease (GERD) and other acid-related disorders. PPIs have
become the third most prescribed category of medications in the US. Concerns have been raised
regarding PPI overuse, potential adverse effects and drug interactions, and costs. In this regard, we
undertook a study in our large outpatient internal medicine clinic, mainly to assess issues of proper
utilization and costs.
Methods: Two hundred-fifty-nine randomly selected medical records were reviewed. The percentage of
patients receiving PPIs during the year 2009 was determined. Source of prescriptions and duration of
treatment was assessed. Diagnosis for PPI use was determined based on history and/or upper
endoscopy findings. In patients with GERD diagnosis, documentation of history details was determined.
H2RA use was also evaluated, as well as prescribing for aspirin, NSAIDs, and clopidogrel.
Results: A total of 259 outpatient clinic patient records were reviewed, mean age 52.6 (19-99), 55.6%
female, 92% Caucasian. During 2009, 83 (32.5%) were taking PPIs. Original source of PPI prescription
was unclear in 54 (65.0%). GERD was listed as the primary diagnosis in 83.1% of PPI patients. History
consistent with GERD was obtained in 29 (34.9%), and/or endoscopy proven GERD was confirmed in 28
(33.7%). In those with recorded GERD history, symptom severity (i.e. frequency, intensity of symptoms,
and nocturnal symptoms) was obtained in 32.6%. “Abdominal pain” was a listed diagnosis in 27
(32.5%), along with other non-specific complaints. Peptic ulcer disease was recorded in 2.4%. H2RAs
were used in 28 (10.8%) of all patients, 4 in patients taking a PPI. NSAIDS were used concomitantly with
PPIs in 24.1%, low-dose ASA with PPI in 50.6%, ASA/Plavix with PPI in 9.6%. In no patients was
gastroprotection listed as reason for PPI use.
Conclusion: PPIs were used in one-third of our clinic patient population during 2009. “GERD” was the
most commonly listed diagnosis in PPI patients, but documented in only one-third. History of GERD
symptoms was usually not adequate to determine symptom severity, i.e. whether inexpensive/lowadverse
effect H2RA therapy would be appropriate as initial treatment in those with only mild to
moderate symptoms. Other indications for PPI use, including gastroprotection in certain ASA/NSAID
pts., were commonly unclear or not provided. Hence, in our clinic, PPI prescribing indications are vague,
PPI use may be excessive, and H2RA therapy is probably underutilized. Quality improvement initiatives
have been undertaken to ensure appropriate PPI use, obviate potential PPI adverse effects, and to lower
costs.
157

WEST VIRGINIA POSTER FINALIST - RESEARCH Cynthia E Collins, DO
Improving Patterns of Urinary Catheter Use
Cynthia E Collins, DO Second Author: Molly John, MD Third Author: Heather Grome, BS Fourth Author:
Stephanie Thompson, PhD
Introduction: An estimated 4 million patients receive urinary catheters annually and are exposed to
catheter associated complications. Thirty percent of health care associated infections are UTI, 80% of
which are associated with urinary catheter use. Thus, catheter associated UTIs (CAUTI) compromise
patient health and increase hospital costs and lengths of stay. While rates of death and serious
complications due to catheterization is generally low, the high frequency of catheter use in hospitalized
patients causes the burden of catheter associated urinary tract infections (CAUTI) to be substantial for
healthcare systems. The goal of our study is to retrospectively examine urinary catheter use at CAMC in
general medical patients older than 50 years. We will determine the patterns of urinary catheter use,
complication rates and indications for catheter placement in the patient group. This information will be
used to determine if and where education should be targeted to decrease excessive urinary catheter
use.
Methods: This retrospective study looked at general medicine patients aged 50 years and older
admitted to CAMC from 3/1/2010 to 9/30/2010. Patients under 50 years of age, admitted to the ICU,
presenting with indwelling urinary catheters, trauma patients, or who have an attending physician who
is not associated with CAMC hospitalist or Internal Medicine Department were excluded.
Results: Of the 7919 patients meeting the inclusion criteria, 1792 received a catheter (23%) The
average age for catheter was 73yrs versus 69yrs for no catheter. Average length of stay was 4.5 days for
no catheter and 6.9 days with catheter. In the catheter subgroup, 9 of 162 had a documented UTI after
receiving urinary catheter. Similar to other studies, we found catheter placement more likely in female,
elderly patients. The majority of patients received the catheter in the ED (56%) before transferring to
the medical floor. The average length of catheter placement was 4 days.
Conclusion: Limiting catheter use is important in helping to decrease the number of CAUTI. Strategies
that have been shown to be beneficial include physician reminders by nurses and electronic reminders
that a catheter was placed in the ED. We now have computerized physician order entry and nurses
clinical assessment in place. Nurses are required to assess if the catheter use is appropriate and
recommend removal if not needed as part of their clinical assessment. We are working to make the
indications for a catheter a mandatory part of ordering. We plan to go back and collect the same data
after these changes are in place.
158

WEST VIRGINIA POSTER FINALIST - RESEARCH Adam H Maghrabi, MD
The Impact of Automated Protocol in Management of Diabetic Ketoacidosis (DKA)
Adam H Maghrabi, MD
Introduction: DKA is characterized by the triad of hyperglycemia, ketonemia and metabolic acidosis.
DKA can potentially result in significant morbidity and mortality DKA hospital admissions and
management poses a huge economic burden to health care delivery system. Fluid, insulin and potassium
replacement are among the primary important factors in the management of DKA.
Our aim is to determine the effect of implementation of an automated protocol for management of
Diabetic Ketoacidosis (DKA).
Methods: Our study is a retrospective chart review of DKA patients managed one year before and after
the automated DKA protocol implementation at a tertiary care hospital. Patient’s medical records and
laboratory data base were reviewed.
Results: There were 88 patients managed one year prior (control group) and 70 patients managed one
year after the implementation of automated DKA protocol (study group). Total time required for
resolution of the DKA was significantly shorter in the study group compared to the control group [11.5
(8.1-17.1) hours vs. 8.5 (5.8-12) hours, P = 0.0078]. Hypoglycemic events were significantly lower in the
study group as compared to the control group [P = 0.029]. There was no difference in the potassium
abnormalities and rate of decline of glucose. On a 1-10 scale survey, most of the nurses and doctors
found the protocol safe, and effective for prompt communication among them.
Conclusion: Our study showed that implementation of an automated protocol reduced the DKA
resolution time and hypoglycemic events without compromising electrolyte imbalance.
159

WISCONSIN POSTER FINALIST - RESEARCH Dajun Wang, MD
Omega-3 Polyunsaturated Fatty Acids Decrease Caveolin Expression in Cardiac Fibroblasts -- One
Possible Mechanism of Fish Oil's Cardiac Benefits.
Dajun Wang MD
Introduction: Heart failure is the leading reason for hospital admissions and is the most expensive
Medicare expenditure. About half of heart failure cases are due to diastolic dysfunction. One of the main
causes of diastolic dysfunction is cardiac fibrosis. Previous study demonstrated that Omega-3
polyunsaturated fatty acids [?-3 PUFAs, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)]
prevent overload-induced cardiac fibrosis and cardiac dysfunction by blocking TGF-ß1-induced phospho-
Smad2/3 nuclear translocation through activation of the cGMP/PKG pathway in cardiac fibroblasts.
Previous study also demonstrated that in cardiac fibroblast, EPA and DHA increase cGMP levels by
increasing phospho-eNOS and eNOS protein levels and nitric oxide production. Caveolin is the principal
structural protein in caveolae, which interacts with endothelial NOS (eNOS) and leads to eNOS
inhibition. Therefore, we tested the hypothesis that EPA and DHA decrease Caveolin expression in
cardiac fibroblasts.
Methods: Confluent cultures of adult mouse cardiac fibroblasts in 6-cm collagen-coated plates were
incubated in the presence or absence of the indicated control, DHA or EPA for 24 hours. Western Blot
analysis was carried out to determine protein levels of Caveolin and GAPDH. GAPDH was used as the
internal control.
Results: Compared with control, DHA (10 mM) and EPA (10 mM) significantly reduced Caveolin/
GAPDH ratio in cardiac fibroblasts (72% and 65% reduction, respectively P

ASSOCIATE VIGNETTE PODIUM PRESENTATIONS
161

CALIFORNIA PODIUM PRESENTATION - CLINICAL VIGNETTE Maria E Andrae-
Hammond, MD
Autoimmune Pancreatitis as a Manifestation of IgG4-related Systemic Disease
Maria E Andrae-Hammond, MD
INTRODUCTION: Autoimmune pancreatitis (AIP) is an increasingly recognized form of chronic
pancreatitis. Its presentation often mimics pancreatic cancer; however, it responds dramatically to
steroid therapy. Autoimmune pancreatitis is diagnosed by characteristic clinical, serological,
morphological and histopathological features and appears to represent one manifestation of IgG4related
systemic disease (IgG4-RSD).
CASE PRESENTATION: A 75-year-old Chinese man with a past medical history of allergic rhinitis,
remote partial gastrectomy, chronic Hepatitis C and recent right-sided submandibular mass presented
with anorexia, abdominal pain and low-grade fever. He was moderately tender to palpation over the
epigastrium and had elevated amylase (222) and lipase (505) levels. CT abdomen demonstrated mild
congestion of the posterior pancreas, infiltrative lesions within the kidneys and abnormal thickened soft
tissue around the abdominal aorta indicative of aortitis. Abdominal ultrasound demonstrated a focal 3cm
hypoechogenic lesion in the pancreatic body, suspicious for neoplasm. These findings, together with
the biopsy report of the right submandibular gland indicating fibrosing sialadenitis with markedly
increased numbers of IgG4 positive cells, suggested the clinical diagnosis of IgG4-RSD, supported by an
elevated ESR of 75, + RF, +ANA, + anti dsDNA, and a high normal IgG level. The patient was treated with
prednisone 30 mg twice daily; lipase levels normalized and clinical symptoms subsided. After several
weeks prednisone was tapered and the patient was maintained at 10 mg daily. Abdominal MRIs at 2
months and 6 months demonstrated resolving inflammatory aortitis as well as disappearance of the
pancreatic mass.
DISCUSSION: Autoimmune pancreatitis is a rare disease, first described in Japan in the 1990’s. It is
twice as common in men as in women, and most patients are older than 50. Multiple organs, including
the pancreas, biliary tree, salivary glands, kidneys, lungs, aorta, colon and thyroid glands, can be
affected simultaneously but more often metachronously, with striking histopathologic similarities. This
has led to the concept of IgG4-RSD, for which the exact pathophysiologic mechanisms are still unknown.
Diagnostic criteria in the US are based on histological, imaging and serological characteristics as well as
extrapancreatic involvement. Patients present with abdominal pain, with or without frequent attacks of
pancreatitis (30%), obstructive jaundice (63%), diffuse enlargement of the pancreas on CT and US (85%)
mimicking pancreatic carcinoma, and/or narrowing of the pancreatic duct. Important markers include
elevated serum IgG4 levels to > twice normal, anti–PBP peptide and carbonic anhydrase II and
lactoferrin antibodies. ANA or RF can also be found.
Corticosteroids alleviate symptoms, decrease the size of the inflamed pancreas and reverse histologic
changes. Incomplete responses, flares or relapses on steroid therapy can be treated with azathioprine,
methotrexate, mycophenolate mofetil, cyclophosphamide and B-lymphocyte-depletion drugs such as
rituximab.
162

FLORIDA PODIUM PRESENTATION - CLINICAL VIGNETTE Andrew D Timothy,
DO
A Case of Uninhibited Inhibition: Opposition to Factor VIII
Andrew D Timothy, DO, MS Du Thuy Tran, PharmD Arjun Mohan, MD Sharad Virmani, MD
INTRODUCTION: Acquisition of autoantibodies to Factor VIII (FVIII) is a rare entity, occurring at a rate
of less than 1 case per million per year. Potential hemorrhagic complications are estimated to be fatal in
14-22% of cases. With limited evidence on treatment, eradication of FVIII inhibitors remains
challenging.
CASE PRESENTATION: A 55-year-old Caucasian male with a history of bladder cancer presented with a
progressively painful mass in the left posterior calf over the course of one-week associated with
increasing pain affecting ambulation. Patient admitted to the use of a fluoroquinolone for a URI twodays
prior. Physical exam revealed a blood pressure of 98/68, heart rate of 101 bpm, ecchymosis on the
left upper arm, swelling and tenderness in the left calf with 4/5 weakness in the left-lower extremity and
reduced range of motion at the knee. Preliminary labs revealed a hemoglobin of 6.6 g/dL and an
activated partial thromboplastin time 74.4 seconds. A CT of the left leg with contrast confirmed a 12 x
9.4 cm intramuscular hematoma involving the soleus and gastrocnemius muscles. Subsequent mixing
study revealed near correction of PTT. Measured FVIII was deficient at 11%. Intermittent and
continuous infusions of recombinant FVIII resulted in further decline of FVIII at 6%. A high inhibitor titer
was documented at 17 Bethesda Units (BU), confirming the presence of FVIII inhibitors. Multiple
transfusions of packed red blood cells and cryoprecipitate were required due to substantial soft-tissue
bleeds during hospital stay. A prolonged course of high-dose intravenous corticosteroids combined with
two trials of high-dose intravenous immunoglobulin (IVIG) paradoxically yielded an increased inhibitor
titer to 29 BU. A trial of Rituximab was initiated; however hypotension secondary to hemorrhagic
complications prematurely ended this regimen. A left-sided retroperitoneal hematoma, sub-acute
compartment syndrome of the left arm and recurrent hematuria occurred successively during
hospitalization. Attempts to restore hemostasis were unsuccessful and the patient expired soon after.
DISCUSSION: Derivation of autoantibodies to FVIII is cryptogenic in half of reported cases, with
remaining causes stemming from autoimmune diseases, medications, post-partum period, or
malignancies. With a negative autoimmune work-up in our patient, presence of FVIII inhibitors were
potentially attributed to recent fluoroquinilone use and/or his underlying malignancy. Treatment with
cyclophosphamide was avoided in this case because of cytotoxic toxicities including hemorrhagic
cystitis. Inhibitor clearance with steroids may achieve remission in 30% of cases while there is a
reported 50% response rate to high-dose IVIG. Reports of Rituximab utilization have demonstrated a
clinical response within a week. This case emphasizes the elusive nature of autoantibodies targeting
FVIII and resistance to multi-treatment eradication therapy.
163

ILLINOIS PODIUM PRESENTATION - CLINICAL VIGNETTE Mudita Bhugra, MBBS
Levamisole-Induced Pseudovasculitis
Mudita Bhugra, MBBS Samih Mawari,MD Swapna Devanna,MD Thamilvani Thiruvasahar,MD Anne
Miller,MD
INTRODUCTION: Levamisole was initially discovered as an anti-helminthic agent in the 1960s. It was
subsequently found to have immunomodulatory effects and was used in the treatment of nephrotic
syndrome, colon cancer, and rheumatoid arthritis. Recently, attention has been focused on the use of
levamisole as a cutting agent in cocaine, and linked to cutaneous vasculitis.
CASE PRESENTATION: JS is a 50 Year old male with history of polyarthralgia who was admitted with a
rash for two days that initially appeared around his ears and nose and then became generalized. It was
associated with severe burning pain in the involved areas. His vital signs were stable at presentation.
Examination revealed extensive, deep purple, non blanching, reticular purpura with early blistering at
the ear lobes, tip of the nose, upper thighs and small scattered areas. Lab testing was remarkable for a
WBC count of 2.4 K/cumm (3.4-9.4) with an absolute neutrophil count of 1.2 K/cumm (1.8-6.5) and urine
toxicology screen positive for cocaine. Based on the reticular pattern of rash and urine toxicology
screen, cocaine induced pseudovasculitis was suspected. Further investigation revealed positive
serology for antinuclear antibody (ANA) with a titer of 1:160 in a diffuse homogenous pattern,
antineutrophilic cytoplasmic antibodies (ANCA) positive for both MPO and PR3 with a titer of >1:640 ,
and high anticardiolipin IgM antibody. Skin biopsy demonstrated widespread thrombosis of cutaneous
and subcutaneous blood vessels consistent with levamisole-induced pseudovasculitis. The patient was
treated supportively with fluids, pain medications and later had extensive debridement and skin
grafting. During the course of hospitalization he also developed a Coombs positive warm autoantibody
hemolytic anemia for which he was discharged on tapering doses of steroids.
DISCUSSION: Levamisole was first reported to cause vasculitis associated with a livedoid rash in 1978 in
a patient with rheumatoid arthritis. Similar necrotizing vasculitis was reported on earlobes in children
receiving levamisole for nephrotic syndrome. Levamisole- induced pseudovasculitis refers to
pathological findings of fibrin thrombi and hemorrhage within the blood vessel. It is usually localized to
skin but may also involve internal organs. It causes agranulocytosis leaving the patients susceptible to
opportunistic infections and is associated with autoantibody production including ANA, ANCA and lupus
anticoagulant (LAC). It enhances T cell activation and proliferation, and increases neutrophil mobility
and adherence. Diagnostic clues for levamisole- induced pseudovasculitis/vasculitis are leucopenia/bone
marrow suppression, positive ANA, ANCA, ACL, characteristic pathology and detection of cocaine in the
urine. However, diagnosis is a challenge, as most patients withhold the information of cocaine use.
Differentiating levamisole associated pseudovasculitis from other types of primary and secondary
vasculitis is necessary as conventional treatment is usually ineffective without abstinence from cocaine
and it may be associated with significant morbidity and mortality.
164

ILLINOIS PODIUM PRESENTATION - CLINICAL VIGNETTE Emad Uddin Abdul
Samad hakemi, MD
Thrombocytopenia after Blood Transfusion
Emad Uddin Abdul Samad hakemi, MD, Mousami Shah, MD
INTRODUCTION: Post Transfusion Purpura (PTP) is a rare but known reaction to blood transfusions.
Infrequency and lack of readily available diagnostics render the recognition challenging and emphasizes
the importance of clinical judgment.
CASE PRESENTATION: A 46 year-old African American female presented to our hospital with 2 months
shortness of breath on exertion. Physical exam was unremarkable except for severe conjunctival and lip
pallor. She was found to have a Hemoglobin (Hb) level of 4.6 gm/dl. Further work up of her anemia
revealed iron panel and ferritin levels consistent with severe iron deficiency anemia. She reported
previous history of heavy menstrual periods and imaging with pelvic ultrasound revealed uterine fibroid
tumors. She responded well to packed red blood cells (PRBC) transfusions on the day of admission and
her Hb remained stable during the rest of her hospital stay. On admission she had a normal platelet
count which gradually decreased till reaching a nadir of 27,000 / microliter over the course of 9
consecutive days. She had no detectable active bleeding as supported by her stable Hb levels. Review of
her medications revealed two possible culprits including heparin and ranitidine, both were stopped but
platelet counts continued to drop. Heparin Induced Thrombocytopenia (HIT) was less likely after HIT
antibodies were not detected in her serum. No evidence of sequestration could be found and her spleen
was normal in size as shown in a computed tomography (CT) of her abdomen done on the same
admission. In view of her recent blood transfusions and negative work up for other possible causes of
her developing thromobocytopenia, PTP became more likely. Tests for antibodies against platelet
antigens were sent and patient was started on a 500 mg/kg dose of empirical intravenous
immunoglobulin (IVIG). Platelet counts stabilized after two doses of IVIG and increased to near normal
levels just before her discharge. Laboratory results came back and revealed the presence of antibodies
against Human Platelet Antigen-1A (HPA-1A) in her serum, which confirmed the diagnosis of PTP.
DISCUSSION: PTP is a rare alloimmune induced thrombocytopenia disorder with a mortality rate of 10-
20%. Patients are initially sensitized to platelet antigens in previous pregnancies or blood transfusions.
The most reported is Human Platelet Antigen-1A. PTP occurs if a HPA-1A negative recipient is transfused
with blood from a HPA-1A positive donor, which boosts antibodies production causing consumption of
both the donor and recipient’s platelets. The mechanism by which circulating antibodies also affect
recipient’s platelets is not clear, multiple theories are yet to be proven including the” innocent by
stander” theory in which the recipient’s platelets adsorb the immune complexes and get destroyed.
Detecting circulating antibodies against platelet antigens and proving that patient’s platelets are devoid
of the antigen confirms the diagnosis. Usually results are not readily available so physician’s clinical
judgment plays a major role in initiating effective medical therapy with IVIG. Other less effective
therapeutic modalities include high dose corticosteroids and exchange transfusions. Transfusion of HPA-
1A negative platelets is not effective.
165

MASSACHUSETTS PODIUM PRESENTATION - CLINICAL VIGNETTE Rattanaporn
Mahatanan, MD
Anaplasmosis: a case report and series in suburban Massachusetts
Rattanaporn Mahatanan, MD, Felipe Barbosa, MD, Thomas Treadwell, MD
INTRODUCTION: Human granulocytic anaplasmosis (HGA) is an emerging tick-borne infectious disease
caused by Anaplasma phagocytophilum . The clinical manifestations of HGA range from a mild febrile
illness to severe infection with multi-organ system failure. The number of cases has been increasing for
the past several years, particularly in suburban Massachusetts. We report a case of severe sepsis caused
by anaplasmosis and a series of fourteen cases seen in our institution in the last 12 months.
CASE PRESENTATION: A 78 year-old man with history of diabetes presented to Metrowest Medical
Center in June 2011 with generalized weakness for 2 days. On admission, hypotension and hypothermia
(94.3 F) were present. The physical exam was remarkable for
dehydration and an ejection murmur grade 2/6 at the apex. No
splenomegaly or rash was noted. He lives in Framingham, MA
and works in his back yard frequently. Initial laboratory data
showed a white blood count of 7.2 /mm3 with 83% neutrophils,
7% bands, and platelets of 29,000/mm3. Hyperkalemia, mild
elevations of the liver enzymes, and acute severe renal failure
(creatinine of 15.7 mg/dL) were noted. . The patient received
fluids and broad-spectrum antibiotics, including doxycycline, by
vein. On the day of admission, a review of the patient’s
peripheral blood smear revealed inclusion bodies (morulae) in
granulcytes; no parasites were seen. Subsequently, serum PCR
for A. phagocytophilum was positive. He required a brief course
of hemodialysis and rapidly improved, with normalization of
laboratory values.
Case series: Fourteen patients presented to our hospital
between May and November. All patients were from suburban
Massachusetts. The mean age was 67 years and the clinical
Elevated liver enzymes 8 (57%)
features are shown in the table below. There were no deaths,
but two thirds of the patients required hospital admission and
Inclusion bodies in smear 2 (14%)
two were admitted to the ICU, one with sepsis and severe renal failure (case presentation), and one with
hypotension causing demand ischemia. None of our patients had co-infection with Borrelia burgdorferi.
At the onset, morulae were seen in peripheral blood smears of both ICU patients. The diagnosis was
established serologically in all of the patients, but acute sera for anaplasma were negative in all of the
patients.
DISCUSSION: The clinical manifestations of anaplasmosis are highly variable. Host factors, including
older age, are the main determinants of the severity of the infection. Severe infection causing end-organ
166
Features
Age (year)
Mean 67
N = 14
(%)
Range 34-87
Sex (M/F) 6/8
Tick exposure 5 (41%)
Fever 10 (75%)
Thrombocytopenia 9 (75%)

dysfunction can occur, particularly in the elderly. The older age of our patients suggests that
anaplasmosis is probably underdiagnosed in healthy persons. Clinicians in an endemic area must be
aware of this emerging illness in order to initiate prompt treatment. The peripheral smear may lead to a
rapid diagnosis, but if anaplasmosis is suspected, the patient should receive doxycycline and clinicians
should not rely on initial serology.
167

NEW YORK PODIUM PRESENTATION - CLINICAL VIGNETTE Syeda A Batul,
MBBS
The Hidden Clot-A case of 'Non-Paradoxical' Embolism
Syeda A Batul, MBBS Arben Dashi, MD Padma L. Draksharam, MBBS Anjula Gandhi, MD
INTRODUCTION: Although more commonly recognized in association with transient ischemic attacks
and cryptogenic strokes particularly in relatively younger population, a patent foramen ovale should be
considered in patients with evidence of systemic thrombosis who develop paradoxical embolism. The
origin of the thrombus maybe within the deep veins of lower extremities or pelvis in patients with
predisposing factors however, a clot may form within the redundant portion of the atrial septum itself
and there on follow an unpredictable course. Bilateral central pulmonary embolism from a possible
thrombus lodged within the atrial septal aneurysm (ASA) in the presence of patent foramen ovale (PFO)
although not unheard of still represents an uncommon entity. We report here a case of massive central
pulmonary embolism in a patient with previously undiagnosed atrial septal aneurysm and patent
foramen ovale.
CASE PRESENTATION: A 56 year old female with came to the hospital with epigastric burning for a week.
Symptoms were progressive with loss of appetite and weakness. Review of systems was otherwise
negative. Physical examination was remarkable for some non specific tenderness in the epigastric
region. In the emergency room the patient was hemodynamically stable but found to have
hyperglycemia and anion gap ketoacidosis (anion gap 28; large acetone in blood). After receiving initial
care under intensive care unit the patient was transferred to medical floor for further care. Two days
into her hospital course she had complains of dizziness and chest pressure followed by the development
of hypoxia, hypotension and tachycardia. electrocardiogram showed the development of right heart
strain pattern as to opposed to a normal EKG on admission accompanied with a significant elevation in
D-Dimers (3138). CT angiogram of the chest showing bilateral central pulmonary embolism and right
ventricular dilation. Patient was started on full dose anticoagulation while a lower extremity doppler
ruled out venous thrombosis. A transthoracic echocardiogram was also performed showing a
pedunculated highly mobile mass within the left atrium tethered to the inter-atrial septum. The
differential diagnosis at this time included endocarditis, intracardiac thrombus or atrial myxoma. A
transesophageal echocardiogram done the following day however, failed to identify the septal mass but
showed instead a large mobile mass within right pulmonary artery. Additional findings included those of
an atrial septal aneurysm with patent foramen ovale. The patient was continued on anticoagulation and
discharged once stable with referral for assessment of closure PFO.
DISCUSSION: Atrial septal aneurysm previously considered a rare entity has been fairly well recognized
since the advent of transesophageal echocardiography. The prevalence in general population is thought
to be around 2-10% with up to 70% of the cases having a co-existing patent foramen ovale. Strokes in
younger patients from paradoxical embolism, migraines with aura or systemic emboli are fairly well
reported in literature but there are some case reports highlighting the entrapment or lodging of
thrombus within the ASA/PFO with subsequent embolization to the pulmonary vasculature.
Transthoracic echocardiography may not be always be diagnostic however, the yield may be increased
with transesophageal echocardiograpy or newer modalities such as 3-dimensional echocardiography,
contrast enhanced dynamic MRI or ECG gated multidimensional CT angiogram where available. A
thromboembolic event with evidence of PFO mandates closure. Percutaneous closure techniques are
employed for this purpose with great success and minimal procedural complications.
168

PENNSYLVANIA PODIUM PRESENTATION - CLINICAL VIGNETTE Dhavalkumar
P Sureja, MBBS
Severe Hypertonic Hyponatremia following Cardiac Catheterization in a Patient with Normal Kidney
Function
Dhavalkumar Sureja, MD, Robert Grunberg, MD, Ravi Makwana, MD, Mahesh Krishnamurthy, MD FACP
INTRODUCTION: Hyponatremia is common in hospitalized patients, particularly after surgical
procedures and is associated with higher mortality. Impaired kidney function is associated with increase
morbidity and mortality after primary coronary intervention. A correlation between administration of IV
contrast and the development of hyponatremia is known in patients with advanced renal disease.
However, contrast induced hypertonic hyponatremia in patients with normal renal function is
uncommon and severe hyponatremia is rare. Hyponatremia can develop within hours after the
procedure and resolves rapidly thereafter. We report a case of contrast induced severe hyponatremia in
a patient with normal renal function.
CASE PRESENTATION: This is a 52-year-old male with no significant past medical history presented
with chest discomfort and shortness of breath. His stress test was abnormal, and he underwent cardiac
catheterization which showed multi-vessel coronary artery disease requiring stenting. In the morning
before the procedure, the patient had blood urea nitrogen (BUN) 17 mg/dl, creatinine 0.9 mg/dl, serum
sodium 140 mEq/L, potassium 4.2 mEq/L, chloride 105 mEq/L and bicarbonate 28 mEq/L. During the
procedure, he developed pulmonary edema and required intubation. Thereafter, he experienced
recurrent episodes of ventricular tachycardia/fibrillation which led to multiple cardio-versions. After a
very complicated and prolonged procedure where >200 ml of contrast was used, an intra-aortic balloon
pump was inserted due to hypotension. The balloon pump was removed within seven hours post
catheterization and subsequent labs later that day revealed a serum sodium 115 mEq/L, potassium 6.6
mEq/L, chloride 86 mEq/L, bicarbonate 20 mEq/L, BUN 16 mg/dl, creatinine 1.3 mg/dl, and serum
osmolality 328 mOsm/kgH2O. Urine osmolality, sodium, potassium, chloride, creatinine were 475
mosm/kgH2O,

PUERTO RICO PODIUM PRESENTATION - CLINICAL VIGNETTE Cristy Gianna
Martinez, MD
Kidney Herbal Supplement, Toxic to the Renal Patient
Cristy Gianna Martinez, MD (Associate), Jose D. Ortiz, MD (Associate), Pedro Colton, MD (Associate),
Otto Ostolaza, MD (Associate), Carlos Rosado, MD, Hector R. Cordova, MD, FACP
INTRODUCTION: The use of herbal medicines and dietary supplements to promote health and treat
various chronic diseases has increased globally. The majority of these supplements have not been tested
for efficacy and safety. Their chemical composition is not always well-established, and the dosage and
route of administration are not standardized. The problems and concerns of herbal supplements arise
from intrinsic toxicity, adulteration, contamination, substitution, misidentification, mistaken labeling, or
poor quality control. Co-administration of herbal medicines with conventional drugs raises the potential
of herb-drug interactions, which may cause altered drug elimination or toxicity.
CASE PRESENTATION: A 55 y/o man with medical history of Chronic Kidney Disease Stage IV
secondary to Type 2 Diabetes Mellitus, HCV s/p liver transplant (2000) with recurrence on chronic
immunosuppression, coronary artery disease, arterial hypertension, and dyslipidemia developed
weakness while at the grocery store. Once at home, he was hypotensive (85/53mmHg) and bradycardic
(44bpm). His chronic medications included mycophenolate, cyclosporine, captopril, isosorbide,
metoprolol, and nifedipine. A week before this event, he had started a natural supplement called
Transfer Factor KBU (Kidney, Bladder, and Urinary Tract). At the ER he was found with hyperkalemia of
9.6mEq/L with associated peak T waves, bradycardia (48bpm), and a first degree AV block in EKG.
Medical therapy for hyperkalemia including insulin IV, dextrose, Kayexalate, and calcium gluconate was
administered with consequent resolution of ECG changes and decreasing trend of serum potassium. The
patient was discharged home with instructions to discontinue the Transfer Factor KBU. On follow up
appointments, no recurrence of hyperkalemia was identified.
DISCUSSION: Within the active ingredients of KBU is Dandelion leaf (Taraxacum officinale), a herbal
supplement that has been used as a diuretic and has a high potassium content, which increases the risk
of hyperkalemia. Also it has been shown to inhibit cytochrome P450, that in patients using cyclosporine,
increases drug bioavailability and the risk of cyclosporine-induced hyperkalemia, which is brought about
by suppression of plasma renin activity and induction of renal tubular insensitivity to aldosterone,
resulting in impairment of potassium excretion. To our knowledge, there are no case reports about
Transfer Factor KBU-induced hyperkalemia in the targeted literature. Physicians need to caution their
patients about the use of herbal preparations and educate them about the risks and potentially fatal
consequences of their use.
170

TEXAS PODIUM PRESENTATION - CLINICAL VIGNETTE Richard Wayne Hilliard,
Jr DO
ATYPICAL PRESENTATION oF RECURRENT ADRENAL CELL CARCINOMA
CPT Richard Hilliard, DO (Associate), CPT Tyler Jenkins, DO (Associate), MAJ Kimberly Rieniets, DO
(Member), William Beaumont Army Medical Center, El Paso, TX
INTRODUCTION: Aldosterone producing adrenocortical carcinoma (APAC) is a very rare malignancy. It
usually presents in a clandestine manner with hypertension, potassium wasting or as an incidentaloma.
We present a case of a 62-year-old male who presented atypically with metastatic APAC.
CASE PRESENTATION: Our patient presented in June 2011 for chest pain. During admission he was
found to have mild hypertension, severe potassium wasting and metabolic alkalosis. His potassium was
1.7 on admission and required excessive amounts of IV and oral potassium replacement. He was a poor
historian, however eventually revealed a long history of adrenal disease to include partial left
adrenalectomy in 2004 for a "Pheochromocytoma". During his admission Pheochromocytoma was ruled
out and Conn's syndrome with severe potassium wasting was diagnosed. Adrenal CT imaging revealed a
2.2 x 2.4 x 2.4cm hyperdense nodule of his left adrenal gland and multiple other non-calcified and
calcified nodules near the adrenal mass, in the retroperitoneal space and involving his omentum.
Exploratory laparotomy with excisional biopsy of the omental mass and several diaphragmatic nodules
was performed. Omental mass histology revealed 6 mitotic figures per HPF and a paucity of vacuolated
cells. Immunohistochemical stains had strong positivity for Calretinin, Vimentin and MART-1/melan A.
Inhibin and Synaptophysin were focally blush positive. Pancytokeratin and Chromogranin were negative.
Ki-67 proliferative index approached 15-20%. Modified Weiss criteria was >3, consistent with ACC.
Clinical, biochemical, and histologic findings support APAC diagnosis; however, diagnostic considerations
include an implant from an adrenocortical adenoma secondary to prior adrenalectomy, ectopic
adrenocortical adenoma, extension from adjacent neoplasm, a metastatic process or other entities.
DISCUSSION: Discovery of adrenal incidentalomas is increasing as imaging technologies advance.
Adrenal incidentalomas may be benign or malignant adrenal tumors, metastatic tumors, infection,
adrenal hemorrhage or adrenal hyperplasia. Roughly fifty percent of incidentalomas are benign
adenomas.
Adrenocortical Carcinoma (ACC) is a rare aggressive disease with an estimated incidence of one case per
two million people annually with a female preponderance of 2.5:1. ACC’s can present as non-functioning
tumors or hyperfunctioning tumors. Cushing’s syndrome with virilization is the most common
presentation of hyperfunctioning ACC. APAC account for 6% and Estrogen-producing tumors account for
2% of hyperfunctioning tumors, respectively.
Ten percent of APAC are metastatic at diagnosis and 50% are metastatic by follow up. It is essential to
diagnose and resect this tumor early and to implement continuous surveillance since this malignancy
has a high rate of recurrence and death.
171

VIRGINIA PODIUM PRESENTATION - CLINICAL VIGNETTE Vince Faridani, MD
Acyclovir Induced Rhabdomyolysis
Vince Faridani, MD, Adil Akthar M.D, Nugma Chadha M.D., Jim Mertz M.D.
INTRODUCTION: Acyclovir is an acyclic guanosine analogue used in the treatment of herpes simplex
virus and varicella-zoster virus. Although generally well tolerated, usage of acyclovir may be complicated
by development of acute renal failure in select patients. The following case demonstrates a rare case of
rhabdomyolysis induced acute tubular necrosis in a patient with on antiretroviral therapy.
CASE PRESENTATION: A 29 year old female with a known history of type I diabetes and end stage
renal disease on peritoneal dialysis presented to the hospital with altered mental status, weakness, and
vomiting. Four days prior she was started on oral acyclovir therapy for treatment of genital herpes.
Upon initial presentation, afebrile, vital signs stable. Physical examination revealed the patient to be
confused and not orientated x 0, no focal neurological deficits. Initial evaluation, CT head was negative
for acute injury and lumbar puncture revealed CSF to be normal. Laboratory studies, Na 122, K 3.7, BUN
87, Creatinine 12.3, and Phosphorus 11.2, creatine kinase (CK) 20,199. Serological work including ASO
titers was negative. HIV viral load was undetectable. The patient was immediately discontinued from her
acyclovir, given IV fluids, underwent emergent hemodialysis for two consecutive days given her acute on
chronic renal failure, altered mental status, and elevated CK. Nearly 48 hours later her CK decreased and
mentation returned to baseline. Hemodialysis was discontinued and she resumed her peritoneal
dialysis.
DISCUSSION: The mechanism of acyclovir-induced acute tubular necrosis classically involves the
administration of intravenous acyclovir leading to precipitation of crystals within the nephron tubules
and renal parenchyma. However the above case highlights a different physiologic mechanism whereby
oral acyclovir can lead to reversible rhabdomyolysis-induced uremic encephalopathy and oliguric acute
kidney injury. Clinicians should also be aware that acyclovir-related renal failure can occur with lower
doses of oral therapy as well as rapid IV infusions. This consideration is especially important when
dealing with patients who have underlying chronic kidney disease. These patients warrant lower doses
of acyclovir treatment given their greater predisposition to renal damage.
172

ASSOCIATE VIGNETTE POSTER FINALISTS
173

ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Sheela Subramanyam, MD
Pheochromocytoma: A Cause of Stemi, Transient Left Venticular Dysfunction and Takotsubo
Cardiomyopathy
Sheela Subramanyam, MD(first) Robert Kreisberg, MD(second)
INTRODUCTION: Takotsubo Cardiomyopthy(TC) has been believed to occur due to elevated
catecholamines that can occur for a variety of reasons. A functioning adrenal gland tumor such as a
pheochromocytoma can cause significant elevations in catecholamines resulting in TC. We present a
unique case of a pheochromocytoma causing elevations of catecholamines resulting in an acute
coronary syndrome as well as TC.
CASE PRESENTATION: A 60 year old man with previous history of angioplasty with stent placement
and a pacemaker for sick sinus syndrome was hospitalized with complaints of chest pain radiating to the
left shoulder, jaw and occasionally to the back. He also complained of palpitations, infrequent
headaches,episodes of diaphoresis and labile hypertension ranging from 200/110mm of Hg to 60/40
mm of Hg for the past month. Three months previously he had presented with pericarditis and
pericardial effusion for which a pericardial window was performed. His past history reveals atrial
fibrillation, dyslipidemia, hypertension, diabetes, nephrolithiasis and gout. During a recent
hospitalization, he was found to have a 2.1 cm adrenal mass on computed tomography of abdomen. He
had undergone numerous cardiac procedures for paroxysmal chest pain and a stress test done three
months ago did not reveal ischemia.
On the day of admission, the patient was afebrile and his blood pressure was 116/69 mm of Hg. His
electrocardiogram showed ST segment elevation in II, III, aVf, V2 –V4 consistent with anterior and
inferior wall myocardial infarction. These results were also supported by the raised cardiac markers
including troponins-1.944 ng/ml and 1.447ng/ml respectively at entry and six hours later. His continued
home medications were continued and he was started on amlodipine for atrial fibrillation. Two days
later, he underwent cardiac catheterization which showed severe hypokinesis of the anterior, apical and
common inferior wall segment possibly consistent with TC but no obstructive coronary atherosclerosis.
In view of his symptoms and the adrenal mass, he was started on labetolol. Amiodarone was
discontinued because of QTc prolongation and he was discharged to be followed on outpatient basis.
The patient again developed similar symptoms and was readmitted to the hospital. All his lab findings
were normal including cardiac markers except for 24 hour urine total metanephrines(2204 nmol/L),
normetanephrines (994nmol/L) and VMA (7.9mg/24 hrs). A left ventriculogram revealed TC with apical
ballooning of left ventricle and an EF of 20% to 25% . The patient was suspected to have a
pheochromocytoma based on the clinical findings, lab reports and history of adrenal incidentaloma.
Inspite of severe cardiac risk, a decision to perform right adrenalectomy was made and he was started
on phenoxybenzamine for two weeks before the surgery.
The pathological report confirmed the tumor to be a pheochromocytoma. After resection, his condition
drastically improved and a repeat ventriculogram showed an improvement in ejection fraction and
reversal of wall motion abnormalities.
174

DISCUSSION: Pheochromocytomas are rare neuroendocrine tumors responsible for 0.3% of the cases
of secondary hypertension that are investigated and more than 4% of the incidental adrenal masses
found by imaging for non-adrenal complaints.Typical symptoms including the triad of headache, labile
hypertension and diaphoresis raise the suspicion of pheochromocytoma but their absence can present a
great challenge in diagnosis. This tumor can be deceptive and presentations can vary from back pain to
severe cardiac manifestations and acute renal failure. The manifestations of these tumors differ
because of the different effects of the catecholamines and the relative proportions of the type of
catecholamine produced. Tumors which produce only norepinephrine generally present with
uncontrolled hypertension, however the tumors which produce both epinephrine and nor-epinephrine
manifest with episodic hypertension. Catecholamine secretion in pheochromocytomas is not regulated
in the same manner as in healthy adrenal tissue. Pheochromocytomas are not innervated, and
catecholamine release is not precipitated by neural stimulation. The trigger for catecholamine release is
unclear, but multiple mechanisms have been postulated, including direct pressure, medications, and
changes in tumor blood flow .
The unusual presentations include rare cardiac manifestations such as an acute coronary syndrome,
rhythm disturbances such as ventricular tachycardia, ST elevation, QTc prolongation and T wave
changes, reversible cardiomyopathy, systolic heart failure and cardiogenic shock. It has been noted that
right sided pheochromocytomas are more likely to be associated with clinical symptoms and
electrocardiographic abnormalities. In the case reported above, the patient had symptoms of acute
coronary syndrome with ECG changes and also TC.
Proposed mechanisms for TC include epicardial spasm, microvascular dysfunction, hyperdynamic
contractility with midventricular or outflow tract obstruction and direct effects of catecholamines on
cardiomyocytes.
The effects of norepinephrine (NE) and epinephrine (E) on ventricular myocytes have been extensively
studied. NE acts on the ß1 and E on the ß2 adrenergic receptors; the latter are abundant in the human
ventricular myocardium. In transgenic mice, physiological levels of NE and E act on their respective
receptors and activate Gs protein, creating a positive inotropic effect and increased contractility.
However at supra-physiological levels of E, a negative inotropic response occurs, resulting from a switch
in signaling from Gs to Gi; a phenomenon called “stimulus trafficking.” “Stimulus trafficking” has been
proposed as a mechanism which prevents excess catecholamine-mediated damage to the myocytes.
After the restoration of physiologic catecholamine levels, ß2 receptors reverse to Gs stimulation allowing
myocyte recovery. ß2 receptors occur in greater abundance at the apex relative to the base of the heart
which may explain why E affects the apical region of the heart in stress cardiomyopathy.
175

ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Phillip K Henderson, DO
A Catastrophic Diagnosis: Case Report of Asherson’s Syndrome
Phillip Henderson, DO University of South Alabama Department of Internal Medicine
INTRODUCTION: Catastrophic Antiphospholipid Antibody Syndrome (CAPS) or Asherson’s Syndrome is
a rare syndrome characterized by rapidly progressive multi-organ system failure, multiple small vessel
thrombosis and positive antiphospholipid antibodies. This syndrome is predominately found in women
with known systemic lupus or primary antiphospholipid syndrome; however, can be found in patients
with no prior history of rheumatologic disease. CAPS should be considered in rapidly declining patients
presenting with microangiopathies with or without a previous history of rheumatologic disease.
CASE PRESENTATION: A 60-year-old Vietnamese female presented with shortness of breath, fatigue,
and arthralgias. Physical exam revealed muffled heart sounds and decreased breath sounds at the lung
bases. Echocardiogram revealed a pericardial effusion with impending tamponade. Emergent drainage
was performed. After drainage she developed respiratory distress requiring ICU monitoring overnight.
She initially improved but then declined. She rapidly developed multi-organ system failure including
coagulopathy, renal failure, obtundation, acute liver injury, and hemodynamic collapse with associated
digital ischemia. Cultures did not reveal a source of infection. The evaluation of her coagulopathy
showed an increased PT, PTT and fibrin split products, but normal fibrinogen. The patient’s platelets
were persistently below 20,000/mcl. The peripheral smear showed decreased platelet numbers but no
schistocytes; however, ANA was found high positive. Further autoimmune workup revealed a positive
anti-smith, high dsDNA titers, and undetectable complement levels. When signs of digital thrombosis
developed lupus anticoagulant was performed which showed presence of a lupus-type inhibitor. Given
the appearance of a rapid thrombotic coagulopathy coupled with a positive lupus anticoagulant, the
diagnosis of probable catastrophic antiphospholipid antibody syndrome (CAPS) was made. High dose
pulse corticosteroids were initiated as well as plasmapharesis. Her organ dysfunction resolved after
treatment was initiated. Despite aggressive care the patient’s platelet count remained persistently low,
so rituximab was implemented and platelet dysfunction resolved. One week after treatment, she
developed an intraparenchymal hemorrhage and expired several days later.
DISCUSSION: This case demonstrates a life-threatening complication of systemic lupus. There have
been approximately 300 reported cases of CAPS. The diagnosis of CAPS is challenging due to the great
overlap with the other thrombotic microangiopathies. To make the diagnosis of CAPS preliminary
criteria are in place which include evidence of three organ system dysfunction with rapid onset of
dysfunction within one week, tissue evidence of small vessel occlusion, and positive antiphospholipid
antibodies. Treatment should be initiated if high index of suspicion due to the high risk of mortality of
around 50%. Anticoagulation, corticosteroids and plasmapharesis are the cornerstone of initial therapy
to reverse the multi-organ insult of CAPS. For refractory cases of immune related anemia and
thrombocytopenia rituximab has been shown to be effective.
176

ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Nicholas L Sparacino, DO
Croaking on Crocus
Nick Sparacino, DO Lise Harper, MD
INTRODUCTION: Colchicine is an ancient drug extracted from plants of the lily family and is used
primarily for its anti-inflammatory properties in gouty arthritis. It has a narrow therapeutic index and
can therefore result in serious toxicity and death if used inappropriately.
CASE PRESENTATION: A 74-year old female with a history of osteoarthritis and chronic pain was
admitted to the general medicine ward with symptoms of nausea, vomiting, diarrhea and
dehydration. Initial work-up found her to have acute myocarditis, pancytopenia, acute renal failure and
elevation of her hepatic function tests. Her non-specific constellation of symptoms presented a
diagnostic dilemmna further confounded by her recent extended visit to Iran. A thorough history
revealed chronic administration of high-dose IV colchicine (a drug no longer available for use in the
United States) for treatment of her chronic joint pain by a local naturopathic physician.
The patient was resuscitated and treated with supportive measures, with ultimate resolution of
symptoms and labratory abnormalities. Though she subsequently developed peripheral neuropathy as
well as the characteristic alopecia, she was fortunate to improve considerably and was discharged to
home.
DISCUSSION: Colchicine containing plants were first recognized as having both therapeutic and toxic
properties by Egyptians as early as 1500 BCE. The therapeutic use of colchicine proper dates to the early
19th century, and is prescribed primarily for its anti-inflammatory effects in gout and other
inflammatory conditions. It acts by binding intracellular tubulin, which in turn inhibits microtubule
polymerization and spindle formation and ultimately hinders cellular mitosis. As microtubules are
ubiquitous in human cells, disruption of their function can have widespread detrimental
effects. Toxicities primarily manifest initially as gastrointestinal symptoms with supsequent dehydration
and hypovolemia. Many other organ systems can be affecteed, including cardiovascular, respiratory,
neurologic, hematologic, renal, musculoskeletal, and integumentary. Its narrow therapeutic index
allows for these serious adverse effects to arise rapidly. Though colchicine has both oral and IV
formulations, the FDA has taken the IV form off the market given the severity of its toxic effects. This
case was notable for both the diagnostic challenge as well as the ethical dilemmna involved.
177

ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Peter V Cherian, MD
Difficult Situation: Bleeding in a Patient with an Acquired Factor VIII Inhibitor.
Peter Cherian, MD, Nalini Tirumalasetty, MD Alison Stopeck, MD
CASE PRESENTATION: 79-year-old male with a history of atrial fibrillation and deep venous thrombosis
developed osteomyelitis and staphylococcus sepsis secondary to trauma sustained in a MVA. He was
discharged on IV nafcillin and coumadin. He was readmitted 2 weeks later for significant bleeding from
his left lower extremity. His hemoglobin had decreased from 10.9 g/dl to 7 g/dl. Coumadin was
discontinued and he was treated with fresh frozen plasma and multiple blood transfusions. Despite
therapy, he continued to bleed. Lab studies revealed an elevated PTT which did not correct on mixing
with normal plasma (mixing study). Factor VIII levels were 172 BU. He was diagnosed with an acquired factor VIII inhibitor and treated with low dose
rVIIa for his bleeding. He was also started on oral prednisone and cyclophosphamide as therapy for his
inhibitor. The patient's left lower extremity continued to bleed requiring daily transfusions with PRBC
despite rVIIa therapy and thus he received a single dose of FEIBA (Anti-Inhibitor Coagulant Complex
concentrate). Within 2 hrs of FEIBA infusion, he developed an inferior ST-elevation myocardial
infarction. His condition continued to deteriorate and he expired on hospital day 16.
DISCUSSION: Hemophilia A can be congenital or acquired. This case demonstrates acquired Hemophilia
A caused by an autoantibody directed against FVIII. This is a rare bleeding diathesis with an incidence of
1 to 4 per million population. Although uncommon, it is associated with a 90% risk of bleeding and a
mortality between 8-22%. Unlike congenital factor deficiency in which hemarthroses are the usual site
of bleeding, in acquired FVIII deficiency soft tissue and mucosal bleeding are more common. There is a
biphasic age distribution with a small peak between 20 and 30 years and a major peak between 68 and
80 years. Acquired FVIII inhibitors have been associated with autoimmune disorders, postpartum, solid
cancers, hematological malignancies, acute hepatitis B and C and as in this case exposure to
penicillin. The diagnosis is based on an isolated prolongation of the PTT which is not corrected by
incubating the patient’s plasma with an equal volume of normal plasma (mixing study). Decreased levels
of FVIII and a positive Bethesda assay (FVIII inhibitor assay) confirm the diagnosis. Treatment is aimed at
controlling the acute bleeding with bypass agents and ultimately eradicating the FVIII inhibitor. Treating
the acute bleed can be accomplished either by raising the circulating factor VIII levels sufficiently with
infusion of FVIII concentrate or by using bypassing agents such as recombinant activated factor VII or
activated prothrombin complex concentrate. Inhibitor eradication can be achieved by the use of
immunouppressive agents. This case demonstrates the importance of recognizing this disorder as well
as the difficulty in treating it.
178

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Lillian Y Hsu, MD
Systemic Mastocytosis: A Shocking Presentation
Lillian Hsu, PGY2, Scripps Green Hospital/Clinic, La Jolla, CA, Parham Khanbolooki, Division of Hospital
Medicine, Scripps Green Hospital/Clinic, La Jolla, CA
INTRODUCTION: Systemic mastocyctosis is a rare disorder and diagnostic challenge in the absence
of cutaneous manifestations.
CASE PRESENTATION: A 69 year-old Caucasian male with coronary artery disease presented with a
syncopal episode in the setting of one month of diarrhea. The patient endorsed chest pain and was
hypotensive with a systolic blood pressure of 56 mmHg. Physical exam was otherwise unremarkable.
Initial labs showed leukocytosis with mild neutrophilia, anemia (hgb 12.2 g/dl), elevated cardiac
enzymes, and acute kidney injury.Despite antibiotics, intravenous fluids, and vasopressors, the patient
remained hypotensive. Echocardiography demonstrated a LVEF of 45% and multiple wall motion
abnormalities. Emergent coronary angiography revealed no new occlusive lesions and diminished
collateral flow compared to prior angiogram. These findings, in addition to right heart catheterization
hemodynamic measurements, suggested cardiogenic shock due to demand ischemia, possibly secondary
to hypotension. Infectious disease work up was negative. The patient deteriorated, developing shock
liver, renal failure, and worsening cardiomyopathy.A tryptase level, obtained to assess for anaphylaxis,
was elevated at 56 ng/dL (normal

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Rekha A Kumbla, MD
Human Herpes Virus 8 (HHV8) as the Link: A Rare Presentation of Kaposi’s Sarcoma and Primary
Effusion Lymphoma
R. Anjali Kumbla MD, Associate Member, UCLA Olive View Department of Medicine Leland Powell MD,
Faculty, Department of Hematology Oncology, UCLA Olive View Program
INTRODUCTION: Primary effusion lymphoma (PEL) is a rare variant of diffuse large B cell lymphoma,
found mostly in immunodeficient individuals, largely marked by pleural, pericardial and even peritoneal
effusions and rarely presents as an extracavitary lesion. The presentation of PEL in Kaposi’s sarcoma
patients can be missed in the differential amidst the setting of complicated HIV disease delaying
promising therapy.
CASE PRESENTATION: A 29 year old male with a past medical history significant for hypothyroidism
and asthma presented in April 2011 with worsening shortness of breath while on exertion and at rest.
On exam, he was noted to have rales and dullness to percussion at the left lung base as well as
hyperpigmented skin lesions concerning for Kaposi’s sarcoma. The initial differential was broad including
community acquired pneumonia, influenza, pneumocystis pneumonia, and fungal infection. Lab results
revealed the patient was HIV positive. Chest radiograph was notable for a left sided pleural effusion.
Diagnostic thoracentesis was performed and routine examination, including cytopathology and flow
cytometry, was non-diagnostic. The patient was treated supportively and discharged with plan for
HAART. He returned in May 2011 with continued worsening shortness of breath. Bronchoscopy revealed
possible disseminated KS. Per Oncology, he underwent three cycles of Doxil with the addition of
Vincristine on the third cycle for treatment of disseminated KS. His pleural effusion did not resolve.
During cycle three in July 2011, he developed a left neck mass in the supraclavicular region. FNA biopsy
of mass was significant for large atypical lymphoid cells. Immunostains of core biopsy were CD 138+,
HHV8+, MUM-1+, EBV-EBER+, and ki-67 (95%) consistent with a diagnosis of extracavitary PEL. Bone
marrow biopsy for staging did not demonstrate features of infiltration. Patient was started on dose
adjusted Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin (EPOCH) and continues
therapy with symptomatic improvement and stable effusions.
DISCUSSION: It is important to remember the HHV8 association between PEL and Kaposi’s sarcoma
since Kaposi’s sarcoma patients are known carriers of HHV8/KSHV DNA. Cells in the malignant pleural
effusions of PEL are infected with the HHV8 virus. The malignant lymphocytes in PEL have a
characteristic immunophenotype, however the routine flow cytometric panel used by commercial
laboratories will miss this diagnosis. Thus, the possibility of PEL in newly diagnosed HIV and Kaposi’s
sarcoma patients should be strongly considered and clinically assessed especially in the setting of
patients presenting with new onset shortness of breath, pleural effusions of unknown etiology, or nodal
lesions. PEL, while rare, has variable manifestations and is known to have rapid clinical progression with
a median survival of 6 months. However, therapies such as EPOCH after initiation of a HAART regimen
can improve patient’s quality of life and even sometimes lead to remission.
180

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Jaimeet S Chhabra, DO
Anemia, Hypercalcemia, Renal Failure with Multiple Lytic Bone Lesions: It is not Multiple Myeloma
Jaimeet S. Chhabra, DO MPH, Minho Yu, DO
INTRODUCTION: Langerhans cell histiocytosis (LCH) is a rare proliferative disorder of histiocyte
cells. Because of its rarity and clinician’s lack of awareness, the diagnosis of LCH is often delayed or
missed. Here we present a case of patient who presented to emergency room with unrelated
complaints, incidentally found to have hypercalcemia, anemia, renal failure with lytic bone lesions
whom after multiple bone marrow biopsies was diagnosed with LCH.
CASE PRESENTATION: 51 year old Caucasian man presented to the emergency room with blurry vision
and worsening back and hip pain for four months. The patient had significant past medical history of
diabetes and systolic heart failure. Incidental findings of hypercalcemia, acute renal failure and anemia
prompted an admission to internal medicine service for further workup.
There were no significant findings on cardiovascular, respiratory, gastrointestinal, and skin
exams. Dilated eye exam showed bilateral proliferative diabetic retinopathy. Vertebrates and hips were
tender to palpation.
Laboratory exam showed normocytic anemia (10.2 g/dl) with thrombocytopenia (130 x
10e9/L). Hypercalcemia (13.5 mg/dl) and elevated creatinine (2.01mg/dl) with normal albumin was also
present. PTH was suppressed (

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Stacy H Shoshan, MD
Posaconazole Versus Paecilomyces: To Boldly Go Where No Triazole Has Gone Before
Stacy H Shoshan, MD, Peter Le, MD, Sally Slome, MD, Aubrey Ingraham, MD
INTRODUCTION: Paecilomyces is a filamentous fungus that infects immunocompromised patients
resulting in high mortality rates. We are presenting a case of pulmonary Paecilomyces variotti
successfully treated with posaconazole after failing treatment with three conventional antifungals.
CASE PRESENTATION: A 48 year old woman with a past medical history significant for AML treated
with chemotherapy and bone marrow transplant 3 years prior, presented with 2 weeks of fever, night
sweats and shortness of breath. She was taking prednisone, sirolimus, tacrolimus and acyclovir, as she
had stopped her prophylactic bactrim and voriconazole 6 weeks prior. Interestingly, in the past few
weeks she had cleaned out her attic, went to a dusty outdoor festival and visited an area endemic with
Coccidiomycoses.
In the ED, she was febrile, tachycardic, hypotensive and hypoxic. She had bilateral wheezing, mild
leukocytosis without a left shift, and on chest x-ray she had prominent bibasilar and perihepatic
opacities. On admission, she was started on bactrim, meropenem, azithromycin and fluconazole. The
next day, she underwent bronchoscopy which was grossly normal.
Her hospital course was characterized by worsening hypoxia and altered mental status for which she
was intubated, and switched from fluconazole to voriconazole to amphotericin B. On hospital day 23,
the sensitivities were discerned for this patient Paecilomyces, and since posaconazole had the lowest
MIC, it was added on to her medication regimen. Four days later, the patient was extubated. 3 1/2
weeks later, on hospital day 53, the patient was ambulating without oxygen and discharged to SNF with
the plan to continue posaconazole indefinitely as her prophylactic antibiotic. The patient is currently
one year since discharge, working and doing well.
DISCUSSION: Paecilomyces is a fungus found in air, food and soil worldwide. Voriconazole and
amphotericin B are the conventional treatments for Paecilomyces infections, however despite low in
vitro MICs, they are often ineffective in vivo resulting in significant morbidity and mortality. Liposomal
amphotericin B consists of a phospholipid bilayer intercalated with amphotericin B, the active
ingredient. Amphotericin binds to ergosterol in the fungal cell membrane and creates a transmembrane
channel resulting in ion leakage and ultimately cell death.
Posaconazole, on the other hand, prevents ergosterol synthesis thereby inhibiting fungal cell growth.
There is some evidence that in vitro posaconazole and amphotericin B can be synergistic. In conclusion,
this case report goes beyond the in vitro studies to show that in an immunocompromised patient, the
innovative combination of posaconazole and amphotericin B can be used to successfully treat
Paecilomyces variotti pneumonia.
182

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Janet J Abou, MD
A Good Question; TB or not TB
Janet J Abou, MD, Micheal Pfeffer, MD, Raffi Tachdjian, MD MPH
INTRODUCTION: Good syndrome is a rare condition defined as an immunodeficiency in the setting of a
history of a thymoma with low to absent B cells and hypogammaglobulinemia. Patients usually present
between the fourth and fifth decade of life and often with recurrent sino-pulmonary disease, chronic
non-infective diarrhea and opportunistic infections. Our patient was unique in that in addition to his
recurrent pneumonias he presented with a cavitary lung lesion. Good’s syndrome is not typically
associated with Mycobacterium, and only three such cases have been reported. Additionally, our
patient’s cavitary lesion was negative for Mycobacterium, making this an unusual presentation of a rare
syndrome.
CASE PRESENTATION: A 56-year old Ethiopian man with a past medical history relevant for Type A
thymoma resected in 2008 presented with fever, chills, cough, weight loss, and night sweats that
persisted since his resection. He was referred for suspicion of tuberculosis to the UCLA Medical Center
after a chest CT showed a 3.5 cm right hilar region mass.
The patient had a low grade fever, good oxygen saturation on room air and otherwise stable vital signs.
A CBC showed evidence of relative lymphopenia of 1,000. A repeat chest CT revealed an irregular,
cavitating, soft tissue right hilar mass.
Blood and urine cultures including viral serologies and HIV, which along with CMV, AFB,
Coccidiomycosis, Histoplasma, and Aspergillosis were negative. The patient’s induced sputum was found
to be positive for Pneumocystis jiroveci. Given the history of the recurrent pneumonia’s, relative
lymphopenia and an opportunistic infection in an HIV negative person a complete immunologic work-up
was done.
The patient’s cell counts were as follows: CD3 absolute count 540 /cmm, CD 4 absolute count 274 /cmm,
CD8 absolute count 280/cmm, CD19 B-Cell absolute count 1 /cmm, IGA 20 mg/dl, IGG 176 mg/dl
and IGM

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Maria E Andrae-
Hammond, MD
Allopurinol Hypersensitivity Syndrome
Maria E Andrae-Hammond, MD
INTRODUCTION: Allopurinol Hypersensitivity Syndrome is a serious complication of allopurinol
treatment of gout. Diagnostic criteria include a maculopapular rash which can progress to Stevens-
Johnson Syndrome and Toxic Epidermal Necrolysis, internal organ injury, fever, and hematologic
abnormalities. AHS has an incidence of one to four per thousand patients and a 25% mortality
rate. Common causes of death include sepsis, GI bleeds and hepatic failure. Prevention of AHS remains
a major concern among physicians, who are facing an increasing incidence and prevalence of gout in the
US population.
CASE PRESENTATION: An 88-year-old Cantonese woman with a past medical history of hypertension,
Type-2 Diabetes mellitus, hyperlipidemia, chronic renal disease (creatinine 1.4) and gout presented with
nausea and emesis of 24-hour duration. Additionally the patient complained about mild subjective
fevers, loose stool and bloating, which commenced two weeks prior, when she had been started on
allopurinol. On exam she was non-jaundiced, her abdomen was non-tender, non-distended and
Murphy’s sign was absent. ALT (56), AST (55), Alkaline phosphatase (130) and lipase (334) were
elevated. CT abdomen demonstrated a somewhat prominent 9 mm common bile duct. Despite
antibiotic therapy for presumed cholangitis and simultaneously resolving pancreatitis, the patient
deteriorated clinically. She developed a severe generalized maculopapular rash, leukocytosis (WBC 30),
fever (39.7 degrees C) and acute interstitial nephritis. Transferred to the ICU for presumed sepsis, she
was diagnosed with Allopurinol Hypersensitivity Syndrome. Over the next six weeks she improved with
glucocorticoid treatment, hemodialysis and TPN. Her recovery was complicated by numerous severe
electrolyte imbalances, uncontrolled diabetes and a gastrointestinal bleed secondary to stress and
glucocorticoids. One year later her renal function is still compromised with a creatinine of 2.8 and she
has developed profound anemia.
Immediate withdrawal of the offending medication and supportive care are the mainstay of AHS therapy
with possible benefit of systemic steroids if pulmonary, renal or myocardial involvement is present. The
pathophysiology of AHS remains unclear, but is likely a complex interaction of immunology, drug
metabolism, genetics, and infection with or reactivation of latent viruses.
DISCUSSION: The severity of AHS, with its associated high mortality, acute morbidity and frequent
long-term sequelae, warrants strict adherence to indications for allopurinol therapy. Identification of
risk factors such as advanced age, CKD, HCTZ or other diuretic use and the presence of the HLA-B*5801
allele (prevalent in Asian populations), should also prompt the prudent use of allopurinol in select
patient populations and therefore reduce the incidence of AHS. In patients with CKD, febuxostat and
intra-articular steroids are effective and well-tolerated alternatives to allopurinol. For Asian populations
preventive genetic testing for HLA B*5801 is becoming a possibility.
184

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Swapna P Busa, MBBS
A Deadly Combination!!
Swapna P Busa, MD Ambar Rahman, MD Uzair Chaudhary, MD and Haifaa Abdulhaq, MD
INTRODUCTION: Plasmablastic lymphoma (PBL) is an uncommon aggressive lymphoma arising most
frequently in the oral cavity of HIV-infected patients. Amyloid light chain (AL) amyloidosis is a relatively
uncommon disorder characterized by the deposition of amyloid fibrils in various tissues leading to
progressive organ dysfunction and death. Ten to fifteen percent of multiple myeloma (MM) patients
have extracellular deposition of amyloid in tissues resulting in amyloidosis. We report an unusual
combination of cardiac amyloidosis, PBL and multiple myeloma in a 65year-old HIV negative woman. To
our knowledge this is the first reported case of PBL with MM and amyloidosis.
CASE PRESENTATION: 65 year old Caucasian woman with no past medical history presented with
dyspnea on exertion and pedal edema and was found to have new onset heart failure. Her BNP was 871
and troponin was 0.198. Her symptoms improved with diuresis and thoracentesis of a large left pleural
effusion. Cytology was negative for malignancy. Patient refused further cardiac workup and was
discharged home in improved clinical condition after medical management of heart failure.
She returned four months later with worsening symptoms. Physical exam was notable for hypotension
and respiratory distress. She was managed with inotropic agents and gentle diuresis. She had mild
anemia but no hypercalcemia or renal dysfunction. Radiology revealed moderate bilateral pleural
effusions. Histologic and immunohistochemical studies of the pleural fluid revealed kappa restricted
large cell population with lymphoid features. The cells were positive for CD45, CD138 and MUM-1. They
were negative for CD10, CD20, CD30, Human Herpes Virus 8 and Epstein bar virus(EBV) with the final
diagnosis of PBL.
SPEP showed no monoclonal gammopathy but kappa light chains were elevated with kappa to lambda
ratio of 18.
Echocardiogram revealed restrictive cardiomyopathy with speckled appearance suspicious for
amyloidosis. Abdominal fat pad aspirate was negative for amyloidosis. Cardiac biopsy revealed AL type
amyloid deposition with kappa restriction. Bone marrow biopsy revealed 60% monoclonal plasma cells.
Skeletal survey done was negative for lytic lesions.
Her clinical condition deteriorated rapidly and she died of cardiopulmonary arrest before chemotherapy
was initiated.
DISCUSSION: Cardiac amyloidosis commonly presents with fatigue, dyspnea and pedal edema. It is
treated with systemic therapy which includes melphalan, bortezomib or cyclophosphamide based
regimens. It carries poor prognosis with a median survival less than 6 months. PBL occurs most
commonly in HIV patients, associated with EBV. In non HIV patients it is commonly EBV negative as in
our patient. Treatment includes aggressive chemotherapy regimens however it carries poor prognosis as
well with a median survival around 12 months. Our patient had cardiac amyloidosis, MM and PBL with a
very poor overall prognosis.
185

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE David J Cho, MD
Calciphylaxis and the Abdominal Wound That Would Not Heal
David J Cho, MD
INTRODUCTION: Calciphylaxis must be considered in any patient with ESRD on hemodialysis presenting
with painful, subcutaneous nodules or open wounds.
CASE PRESENTATION: A 52 year old woman presented to the Emergency Department with a large
right lower quadrant abdominal wound that had steadily increased in size over five months. Her medical
history was significant for ESRD on hemodialysis, diabetes mellitus, coronary artery disease status post
coronary-artery bypass grafting and hepatitis C. According to history obtained from the patient, the
lesion first began as a painful, erythematous nodule on her lower right abdomen, and she received a
course of Amoxicillin for suspected cellulitis. Her nodule continued to grow, however, and she
underwent incision and drainage with additional antibiotics including Clindamycin for empiric coverage
of methicillin-resistant staphylococcus aureus. The wound, now open, continued to rapidly expand with
surrounding necrosis of the skin and subcutaneous tissues. She had several unsuccessful debridements
performed at an outside hospital with further enlargement of the wound prior to admission. On physical
exam, her abdominal wound measured approximately 12cm x 12cm and extended down to the
abdominal fascia. The lateral edges showed evidence of necrosis without purulent drainage. In addition,
she had several painful subcutaneous nodules on her left lower abdomen with mottling of the skin. She
underwent debridement and eschar excision for the right lower quadrant abdominal wound the day
after admission. The left lower quadrant subcutaneous nodules were not disturbed. Surgical tissue was
sent for pathology and showed necrosis and calcification changes consistent with calciphylaxis.
Vasculitic etiologies including cryoglobulins, C3 and C4 complement levels, anti-nuclear antibody, antineutrophil
cytoplasmic antibodies, anti-lupus anticoagulant and anti-phospholipid antibodies were
negative. When the diagnosis of calciphylaxis was established, the patient was started on a
bisphosphonate, hyperbaric oxygen therapy and thiosulfate with dialysis. As her parathyroid hormone
level was not markedly elevated for an ESRD patient on hemodialysis at 170 pg/mL, cinacalcet was not
initiated. Despite medical management and one additional debridement and excision of necrotic tissue,
the abdominal wound continued to enlarge without healing.
DISCUSSION: Unfortunately, calciphylaxis is a rare and serious diagnosis that carries a very poor
prognosis, with mortality as high as 80% after one year. While the mechanism of its pathogenesis is not
clearly understood, it is most commonly seen in patients with ESRD on hemodialysis, and is
characterized by systemic calcification of arterioles leading to ischemia and subsequent subcutaneous
necrosis. The differential diagnosis also includes warfarin-induced skin necrosis and vasculitic etiologies
noted above. Medical therapy is aimed at reducing systemic levels of calcium and phosphate levels. The
usual cause of death from calciphylaxis is overwhelming sepsis from an associated infection of the
wound.
186

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Allison S DeKosky, MD
An Unlikely Foe: Iatrogenic multi-system organ dysfunction
Allison S DeKosky, MD Manisha Israni, MD
INTRODUCTION: Hospitalized patients are often treated aggressively with prolonged courses of broadspectrum
antibiotics. These therapies can have unanticipated and severe adverse effects.
CASE PRESENTATION: A 59 year-old man with diabetes, Stage I congestive heart failure, and COP on
chronic steroids was admitted for surgical treatment of recurrent leg infections. He received two weeks
of vancomycin and piperacillin-tazobactam before a flap repair. Intra-operative calcaneal and wound
cultures grew pseudomonas and the patient was therefore switched to cefepime. Two weeks postoperatively,
repeat deep wound cultures grew resistant enteroccoccus and the empiric vancomycin
(restarted three days prior) was changed to linezolid; cefepime remained on medication list
throughout. Four days later, he was found to be somnolent and confused. Computed tomography of
his brain was normal. Over the next twelve hours, his mental status worsened and he developed facial
edema and a macular, confluent erythematous rash that spread from his torso to his face, ears, and
upper extremities. There was no mucosal involvement. He became hemodynamically unstable with
fever, tachycardia, hypotension and anuria. His creatinine had increased over the previous two days
from 0.7 to 3, while maintaining a normal BUN. He developed leukocytosis with 3.5% eosinophils. His
urinalysis revealed pyuria with no nitrite, bacteria or casts, consistent with acute interstitial
nephritis. He ultimately required vasopressor support in the ICU and continuous veno-venous
hemodialysis. Cefepime was then stopped and meropenem was initiated. Within a few days, his mental
status and renal function improved. No organisms grew on multiple repeat blood and wound
cultures. High-dose steroids were initiated for a concern of DRESS syndrome (Drug Rash, Eosinophilia
and Systemic Symptoms). A biopsy of the rash revealed perivascular infiltrates containing eosinophils.
DISCUSSION: Cefepime hydrochloride, a fourth-generation cephalosporin, is a common tool in
physicians’ arsenals for treating severe infections, especially Pseudomonal infections. Prolonged use of
cefepime increases the risk of complications, which are compounded when renal function
deteriorates. This patient had multiple cefepime-induced toxicities including interstitial nephritis,
characterized by decreased GFR and pyuria in the absence of bacteria; severe neurotoxicity resulting in
profound encephalopathy, more likely to be seen with high doses of cefepime; and the less known
DRESS syndrome. This drug hypersensitivity rash typically develops two to six weeks after the
responsible drug is begun, consistent with this patient’s time course. Fever and erythroderma are
common characteristics, while the facial edema and ear involvement are hallmark features. DRESS
syndrome’s constellation of symptoms can be mistaken for sepsis-induced multi-organ failure or toxic
shock syndrome. Internists should be aware of the unusual but critical complications associated with
commonly used drugs like cefepime.
187

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Paul Di Capua, MD MBA
Acquired Angioedema: A Rare Cause of Transient Bowel Obstruction
Paul Di Capua, MD MBA, Radhika Zopey, MD, Stephen Kim, MD
INTRODUCTION: : A 67-year old female with a history of marginal zone lymphoma and six-month
history of recurrent episodes of abdominal pain requiring hospitalization presented to the emergency
department with severe abdominal pain, multiple episodes of non-bloody emesis, and inability to
tolerate oral intake.
CASE PRESENTATIONOn exam, the patient was afebrile, hypotensive with a blood pressure of 64/36
and a heart rate of 75 beats per minute. She was ill-appearing, diaphoretic, and had diffuse abdominal
tenderness with voluntary guarding and mild distension. Laboratory tests were significant for a marked
leukocytosis with lymphocytic predominance. A computed tomography scan of the abdomen revealed
extensive bowel wall thickening of the entire length of small intestine with mesenteric fat
stranding. The patient was treated with intravenous fluids and empiric antibiotics. Her symptoms
completely resolved within 48 hours. Further laboratory testing revealed low C1 esterase inhibitor
levels, low C4, and an undetectable C1q complement component, consistent with acquired
angioedema. The patient’s acquired angioedema was attributed to her marginal zone lymphoma, and
she is currently receiving treatment with rituximab.
DISCUSSION: Acquired intestinal angioedema is a rare cause of transient, intermittent episodes of
bowel obstruction. This patient carried a diagnosis of splenic marginal zone lymphoma, which has
previously been implicated in the depletion of C1-esterase inhibitor and the development of acquired
angioedema. 1
C1-esterase inhibitor deficiency can be inherited, or, more rarely, acquired, with just over 100 reported
cases. 1 The acquired form is due to consumption of the C1-inhibitor through a paraneoplastic or an
autoantibody-mediated reaction. 2 In the absence of the C1-inhibitor, there is intermittent, inappropriate
activation of bradykinin, thought to mediate the angioedema symptoms seen in these patients. The
clinical presentation of the hereditary and acquired forms of the disorder are similar, differing primarily
with age of onset. 1 Hereditary angioedema typically presents before the age of 20 while the acquired
form usually manifests after age 40. The angioedema episodes can last from two to five days, with
episodic recurrence. Skin manifestations include a non-pitting, disfiguring edema of the face, limbs or
genitals. Angioedema can also lead to life-threatening laryngeal and upper airway edema. Lastly, when
the gastrointestinal tract is affected, bowel wall edema can cause transient bowel obstruction and
severe abdominal pain.
The diagnosis of angioedema requires low levels of C1-esterase inhibitor and C4. A reduced level of C1q
establishes the diagnosis of acquired angioedema. 1 Treatment is generally focused on managing the
associated condition.
1. Cicardi M, Zanichelli A. Acquired angioedema. Allergy Asthma Clin Immunol;6:14.
2. Pappalardo E, Zingale LC, Terlizzi A, Zanichelli A, Folcioni A, Cicardi M. Mechanisms of C1-inhibitor
deficiency. Immunobiology 2002;205:542-51.
188

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Renea Jablonski, MD
Blown Away: An Interesting Diagnosis of Anca-associated Vasculitis
Renea Jablonski, MD
INTRODUCTION: Microscopic polyangiitis (MPA) is a pauci-immune, small-vessel vasculitis that can
present with a wide range of symptoms; the diagnosis of MPA in our patient was made all the more
complex due to the absence of frank necrotizing vasculitis on biopsy. Often, as in this case of hemoptysis
attributed to an ANCA-associated vasculitis, distinguishing between true vasculitis and psudovasculitis
can be difficult, requiring close examination of the nuances of the presentation.
CASE PRESENTATION: A 52 year-old Mexican woman with a history of arthritis treated with
prednisone and methotrexate was admitted with 6 months of night sweats and low-grade fevers, two
weeks of hemoptysis and a 17-kg weight loss. Physical exam revealed perforated nasal septum and
diffuse rales without joint deformities or synovitis. Evaluation for pulmonary tuberculosis was negative,
and the Pulmonary and Rheumatology services were consulted. Bronchoscopy was consistent with
diffuse alveolar hemorrhage; subsequently the patient developed worsening hempoptysis, hypoxia and
respiratory distress necessitating transfer to the medical intensive care unit. Further laboratory analysis
was notable for an elevated ESR, positive p-ANCA (anti-MPO) and microscopic hematuria without
proteinuria. Open lung biopsy showed organizing pneumonia and was negative for evidence of
vasculitis or granulomatous inflammation. Further history revealed ten years of cocaine abuse. The
diagnosis was microscopic polyangiitis in light of her positive p-ANCA and anti-MPO antibodies though a
pseudovasculitis secondary to cocaine abuse was strongly considered in the absence of vasculitis on lung
biopsy. Treatment with pulse-dose methylprednisolone was started, and the patient was transitioned to
a prednisone taper with cyclophosphamide. The patient continues to be on prednisone more than six
months after discharge and has been without recurrent hemoptysis or joint complaints and regaining
weight; follow-up imaging shows essentially complete resolution of organizing pneumonia.
DISCUSSION: The diagnosis of the ANCA-associated vasculitidies often can be difficult; diagnosis is
made using a combination of clinical signs, serologic markers and immunohistological findings. The
history of cocaine use in this patient made the diagnosis more difficult as it can be associated with an
ANCA-positive pseudovasculitis which mimics many of the clinical and laboratory features of the ANCAassociated
vasculitidies without typical pathological findings of vasculitis. Distinguishing features of
cocaine-induced pseudovasculitis are an inconsistent ANCA pattern and target antibodies and the
presence of anti-elastase antibodies. This patient lacked those findings and demonstrated a brisk
response to treatment with corticosteroids and cyclophosphamide suggesting that this case in fact
represents a case of microscopic polyangiitis. This patient had a ten year history of cocaine use and a
three year history of myalgias and joint pain prior to development of hemoptysis; it is possible that the
activation of an autoimmune process in this patient was triggered by chronic cocaine use.
189

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Amirkaveh Mojtahed,
MD
A Case of the Missing Goblet Cells
Amirkaveh Mojtahed, MD, Ahmad Kamal, MD, Subhas Banerjee, MD, Teri Longacre, MD
INTRODUCTION: Autoimmune enteropathy (AIE) is a rare autoimmune cause of intractable diarrhea in
adults. Patients present typically with diarrhea, malnutrition, weight loss, and occasionally abdominal
pain. This disease is characterized by gut autoantibodies and biopsy findings of intraepithelial
lymphocytes, lack of goblet cells and villous blunting. The purported pathogenic theory suggests T cell
dysfunction and a hyperactive immune system. Celiac disease (CD) must be excluded by celiac
antibodies, trial of gluten free diet and CD susceptibility HLA genotype testing. While AIE is a recognized
entity in pediatric gastroenterology literature, it is exceptionally rare in adults with fewer than 30 cases
reported in the literature and only two conclusively associated with thymoma.
CASE PRESENTATION: A 63 year-old man with a history of malignant thymoma resected 20 years
earlier presented for evaluation of chronic diarrhea. He reported up to 10 watery bowel movements a
day throughout the preceding year in addition to a 70 pound unintentional weight loss. His physical
exam was normal. His past medical history was significant only for MGUS and thymoma. His hematocrit
was 38.1%, ESR was 70 mm/hr and albumin was 3.2g/dl. Clostridium difficile toxin assay was negative,
VIP was less than 15 pg/mL, and stool cultures were also negative. Celiac sprue studies including antigliadin,
anti-endomysial and anti-tissue transglutaminase antibodies were also negative. A CT scan of
chest/abdomen/pelvis showed a 2.5 cm paraspinal mass and a 4 cm pleural based lesion suspicious for
recurrent thymoma. EGD and colonoscopy revealed diffuse gastric erythema and mild flattening of the
duodenal folds. Random duodenal biopsies showed absence of goblet cells, decreased Paneth cells,
increased apoptotic bodies, and increased intraepithelial lymphocytes. Colonic biopsies showed similar
findings. Overall, the histopathology was consistent with AIE. Serologic testing was positive for antigoblet
cell antibodies. The patient’s prednisone was resumed at 40 mg/day with marked improvement
of his diarrhea. Repeat biopsy 3 months later revealed continued loss of goblet cells with some Paneth
cell regeneration.
DISCUSSION: The first thymoma associated chronic diarrhea was described in 1966 followed by 4 cases
of thymoma associated GVHD and 2 cases of thymoma associated AIE. It is possible that these cases as
well as the current case all represent a similar disease process. The relapse of this patient’s malignant
thymoma in temporal relation to the presentation of diarrhea strongly implicates the interrelation of
these conditions. Proliferating T cells within a thymoma could possibly result in unselected T cells
entering the systemic circulation. These T cells would then orchestrate an autoimmune response
primarily affecting intestinal epithelial cells causing mucosal damage and diarrhea. In summary, AIE is
rare in adults, yet a high index of suspicion should be maintained for patients diagnosed as refractory
sprue without positive antibodies or who present with chronic diarrhea and history of autoimmune
disease or thymoma.
190

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Nima Naimi, DO
Torsades De Pointes… Or Is It?
Nima Naimi, DO
INTRODUCTION: Torsades de pointes is a form of ventricular tachycardia associated with a long QT
interval. It is defined by a gradual change in the amplitude and twisting of the QRS complex around the
isoelectric line. Although rare, it is a life threatening arrhythmia accounting for almost 5% of all sudden
cardiac deaths.
CASE PRESENTATION: A 61 year old male with a history of alcoholic cirrhosis, stroke, diabetes, and
seizures was admitted with shortness of breath and abdominal distention. On physical exam, he had
increased ascities. CXR showed a pleural effusion. He was admitted to the medicine floor where he
underwent paracentesis and thoracentesis. On the second day of hospitalization, the patient was found
in the bathroom unresponsive. The rapid response team was called after glucose level, vitals, and EKG
were found to be normal. A CT of the head did not find any acute changes. The patient was admitted to
the ICU with acute encephalopathy. Hepatic encephalopathy was thought to be unlikely as the patient
was taking lactulose and had 4 loose stools that day. No opioids or narcotics were given prior to the
mental status change. Once placed on telemetry, his rhythm showed oscillating QRS complexes
suggestive of torsades. No magnesium was given as his level was already elevated at 2.6, and his pulse
did not match the rate on the monitor. EKG showed normal sinus rhythm with a rate of 81 while
telemetry was still showing torsades. The cardiology fellow was called and recommended no treatment
as the EKG was not consistent with torsades. Over the next day, telemetry demonstrated torsades
intermittently. Neurology was consulted due to concern for silent seizures as the cause of
encephalopathy. EEG was consistent with status epilepticus at the same time that telemetry was
showing torsades. The patient was given three doses of Ativan resolving both the status epilepticus on
EEG and the torsades on telemetry. His mental status improved over the next several days, and he was
discharged on higher doses of Keppra.
DISCUSSION: It is imperative to treat torades promptly in order to prevent progression to ventricular
fibrillation. However, if the pulse does not match the telemetry monitor and no change occurs in the
blood pressure, an EKG should be ordered. As highlighted in this case, telemetry may erroneously sense
electrical activity other than that from the heart.
191

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Sajan Patel, MD
A Small Bowel Obstruction Caused by Mycobacterial Spindle Cell Pseudotumor
Sajan Patel, MD Michael Pfeffer, MD David Geffen School of Medicine at UCLA
INTRODUCTION: Mycobacterial spindle cell pseudotumor is an exceedingly rare tumor-like lesion
characterized by spindle-cell and histiocyte proliferation secondary to mycobacterial infection. It usually
affects immunosuppressed patients with or without AIDS and in most cases occurs in lymph nodes.
CASE PRESENTATION: A 63 year-old man with a history of end-stage renal disease status post
deceased donor renal transplant and small bowel carcinoid status post excision presented with fevers.
Infectious work-up was negative, however a CT scan of the abdomen showed mural thickening and fat
stranding around his small bowel anastomosis along with mesenteric lymphadenopathy. This raised
concern for an infectious or inflammatory process or post-transplant lymphoproliferative disorder. The
lymph nodes were not amenable to percutaneous biopsy by interventional radiology, and thus a biopsy
was not pursued. His fevers eventually resolved with empiric antibiotics and he was discharged.
On outpatient follow-up, an acid-fast bacilli urine culture from his hospitalization grew Mycobacterium
avium-complex (MAC). He was prescribed azithromycin and ethambutol.
The patient returned to the hospital several weeks later with left-sided abdominal pain and fevers. A CT
scan of the abdomen showed a small bowel obstruction along with interval enlargement of the
retroperitoneal lymph nodes seen on prior imaging. The patient underwent an exploratory laparotomy
where a tumor was found in the mesentery at the site of the obstruction. This tumor was excised along
with surrounding lymph nodes and the involved segment of small bowel. There was initial concern for
recurrence of his carcinoid tumor or a lymphoma, however surgical pathology and culture identified the
mass as a mycobacterial spindle cell pseudotumor secondary to MAC infection. The patient’s small
bowel obstruction and fevers resolved after his surgery and he was discharged on a two-year course of
azithromycin and ethambutol.
DISCUSSION: Mycobacterial spindle cell pseudotumor (MSP) is a rare presentation of mycobacterial
infection. Less than 30 cases have been reported in the literature since 1985, when MSP was first
described. To our knowledge, this is the first reported case of MSP causing a small bowel
obstruction. Histologically, MSP has been described as an “exuberant spindle cell lesion” that
“resembles a mesenchymal neoplasm”, including Kaposi’s sarcoma. Because of their shared histologic
features and predilection for immunosuppressed hosts, proper identification is important as the two
diseases have distinct prognoses and treatments.
Conclusion: We present a case of Mycobacterium avium-complex that manifested as a mycobacterial
spindle cell pseudotumor causing a small bowel obstruction. Although rare, this entity should be on the
differential in an immunosuppressed patient with unexplained lymphadenopathy. Furthermore, since
pseudotumor histologically resembles Kaposi’s sarcoma, differentiation is critical for treatment and
prognostication purposes.
192

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Rena H Shah, MD
Oriental Cholangiohepatitis: No Longer an Endemic Disease
Rena H Shah, MD
INTRODUCTION: As demographics around the world are shifting, the presentations of diseases are also
changing. What once was only seen in Southeast Asia due to endemic pathogens has become a global
phenomenon in recent years, and has introduced unique disease processes to Western medicine.
CASE PRESENTATION: A 55 year-old Cantonese woman presented to the emergency room with one
week of severe abdominal pain and emesis. On physical exam she was noted to be jaundiced and had
severe tenderness to palpation at the right upper quadrant. Her labs were notable for an elevated
alkaline phosphatase, direct bilirubinemia, and transaminitis. Her CT Abdomen revealed
choledocholithiasis with extensive biliary and hepatic duct dilatation, as well as cholangitis, and a filling
defect in the dilated biliary duct. . She was treated with IV piperacillin and metronidazole.
Subsequently, the patient underwent ERCP for placement of an internal biliary drain for biliary
decompression, and biopsy of the filling defect, which returned as a pigmented stone.
Interestingly, she reported having experienced ten episodes of cholangitis over her lifetime. Between
her bouts of cholangitis, she had suffered from chronic abdominal pain. She also reported spending 15
years in Vietnam. This unusual and complex case sparked an interest on the medicine team, and after
reading various case reports and reviews, we discovered that this presentation was consistent with
Oriental Cholangiohepatitis (OCH). Prior to discharge, interventional radiology performed an internal to
external biliary drain exchange that would remain indefinitely given the high likelihood that she would
have recurrent stone formation. Since then she has routinely followed-up with the GI team, and remains
pain free.
DISCUSSION: OCH is an endemic disease in Southeast Asia, and its incidence is increasing in the West
due to immigration from endemic countries. While the precise pathogenesis is unknown, it is believed to
be a result of chronic infestation of the biliary tract with endemic parasites such as Clonorchis sinensis
and Ascaris lumbricoides. OCH is characterized by recurrent attacks of abdominal pain, fever, and
jaundice. Pathologically, the intra- and extrahepatic ducts are extensively dilated and contain soft,
pigmented stones and pus. It is crucial to understand this disease process as appropriate intervention
can alter its otherwise recurrent nature and poor prognosis. Moreover this highlights the ever-changing
face of medicine, and that as globalization progresses, epidemiology shifts, making it imperative for
practitioners to familiarize themselves with disease processes that were once thought to be exclusive to
a certain part of the world.
193

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Alisson D Sombredero,
MD
Parasitosis Unexpectedly Causing Lymphoma-Like Symptoms in a Patient With AIDS.
Alisson D Sombredero, MD, Howard Edelstein, MD
INTRODUCTION: Fever of unknown origin (FUO) associated with pancytopenia, lymphadenopathy, and
hepatosplenomegaly may be seen commonly in AIDS patients. Prevalent etiologies include M. avium
complex, M. tuberculosis, histoplasmosis, coccidioidomycosis, cryptococcosis, and lymphoma. We
present an unsuspected case of visceral leishmaniasis in a patient residing in the US, and show the utility
of bone marrow biopsy in AIDS patients with FUO.
CASE PRESENTATION: A 47 year-old Guatemalan male with history of HIV diagnosed in 2006 was
treated with antiretrovirals and did well. In June 2010, after a 6 month trip to Arizona, he presented
with a 3 month history of fevers, sweats, weight loss, and fatigue. The patient appeared toxic with a
temperature of 38 C. Physical exam was notable for tachycardia and hepatosplenomegaly.
Laboratory studies showed relative pancytopenia (WBC 4.9 th/µL, hemoglobin 7.6 g/dl and platelets
27,000 th/µL), increased total protein of 11.0 g/dl and a normal CSF analysis. CD4 count was 62
cells/mm3 and the HIV viral load was undetectable. The patient was admitted to the hospital for
suspected disseminated coccidioidomycosis.
The patient was initially treated with fluconazole, which was suspended after several days when
cryptococcus and coccidioidomycosis serologies and cultures were normal. A CT scan of the abdomen
and pelvis showed marked retroperitoneal lymphadenopathy, massive splenomegaly, and mild
hepatomegaly. A diagnosis of lymphoma was considered. Due to a difficult percutaneous access of the
involved lymph nodes, a bone marrow biopsy and aspirate was performed. Surprisingly, microscopic
examination revealed amastigotes, consistent with a diagnosis of visceral leishmaniasis. The diagnosis
was confirmed by the Centers for Disease Control by PCR with a leishmania titer 1:512.
The patient was treated with liposomal amphotericin B for 10 days, followed by six weekly infusions.
Several months later fatigue, pancytopenia, and elevated total protein recurred, and a bone marrow
again showed amastigotes. The patient was re-induced with the same regimen of Amphotericin B,
followed by 3 week suppressive therapy. He did well for several months but recently had his second
clinical relapse. He is currently under re-treatment and doing well.
DISCUSSION: Visceral leishmaniasis (with or without HIV infection) is a rare occurrence in patients
residing in the United States. Based on the patient’s travel history, he was likely infected prior to 2006 in
his home town of Jacaltenango, Guatemala, where visceral leishmaniasis is an endemic zoonosis with
the dog as the reservoir. Interestingly, his infection remained asymptomatic for more than 4 years, even
in the face of very advanced HIV disease. This case demonstrates that patients with HIV may have
unusual or unsuspected opportunistic infections, and underlines the value of bone marrow biopsy in
patients with FUO.
194

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Sowmya P Srinivasan,
MD
Thyrotoxicosis Caused by a Complete Molar Pregnancy: An Unexpected Outcome in a Perimenopausal
Woman
Sowmya P Srinivasan, MD Kasandra White, MD, Erica Sobel, DO, Joan Lo, MD, Liz Han, MD Departments
of Medicine and Obstetrics and Gynecology, Kaiser Permanente, Oakland, CA
INTRODUCTION: Advanced complete molar pregnancies are an uncommon occurrence in the U.S.
because of early detection with ultrasound and sensitivity of bhCG. Incidence rates of molar pregnancy
in the U.S. are estimated at 1 in 2000 pregnancies. However, incidence is 5-15 fold higher in Asian
countries, ranging from 1 in 500 pregnancies in Japan and Vietnam to as high as 1 in 120 pregnancies in
Taiwan. Presenting symptoms of complete moles include abnormal uterine bleeding, preeclampsia,
hyperemesis gravidarum, and increased uterine size (greater than dates). Hyperthyroidism can be
evident biochemically, but initial presentation with thyrotoxicosis is rare. We present an unusual case of
thyrotoxicosis secondary to complete molar pregnancy.
CASE PRESENTATION: A 52 year old Asian woman with no significant past medical history presented to
the emergency department with shortness of breath and palpitations. On exam she had a normal heart
rate, blood pressure and a positive stare without proptosis or lid lag. The thyroid was nontender,
without enlargement or nodules. No tremor. Initial chest x-ray showed bilateral pleural
effusions. Laboratory data revealed a suppressed TSH and elevated free thyroxine level consistent with
thyrotoxicosis. Propranolol was started for symptom control, and differential diagnosis included
thyroiditis versus possible Graves disease given recent atypical pneumonia. Lab returned a positive
urine bHCG with a serum bHCG of 16,000 mIU/mL. Patient, when re-questioned, described two weeks of
abnormal vaginal bleeding. A transvaginal pelvic ultrasound showed an enlarged uterus with fibroids
without intrauterine pregnancy. Endometrial biopsy completed for abnormal bleeding evaluation
demonstrated necrotic tissue and chronic endometritis. Abdomen/pelvis CT scan showed no ovarian
masses. Serial bHCG rose to 75,000 mIU/mL in conjunction with an elevated CA125. The patient
underwent exploratory laparotomy and total abdominal hysterectomy with bilateral salpingoopherectomy.
Pathology uncovered a hydatiform mole invading the myometrium with prominent
vascular involvement. Per protocol of evaluating complete molar pregnancies, head and chest CT were
performed to confirm the absence of metastatic disease. Postoperatively, bHCG declined to 28,000
mIU/ml and methotrexate was initiated for post evacuation prophylactic chemotherapy. After three
methotrexate cycles, bHCG levels were undetectable.
DISCUSSION: The pathophysiology between molar pregnancy and hyperthyroidism involves homology
between the beta-subunits of HCG and TSH. Thus, bHCG has a weak thyroid-stimulating activity. A
pregnancy test should be considered in the evaluation of thyrotoxicosis in premenopausal women with
symptoms suggestive of molar pregnancy, especially in those of Asian descent. A positive bHCG result in
a hyperthyroid patient without interuterine pregnancy should also raise suspicion of molar
pregnancy. While the sensitivity of ultrasound is greater for complete rather than partial moles, normal
sonographic findings in a patient with abnormal bHCG should not preclude further investigation for
gestational trophoblastic disease. Treatment of thyrotoxicosis in complete molar pregnancy is directed
at the evacuation of the mole, resulting in bHCG decline and resolution of hyperthyroidism.
195

CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Ajay Yadlapati, MD
Treatment Of Cirrhosis-associated Hyponatremia Refractory to Vasopressin 2-receptor Antagonist
Ajay Yadlapati, MD; Minhtri Nguyen, MD
INTRODUCTION: Hyponatremia is a common laboratory finding and reason for admission in patients
with end stage liver disease (ESLD). Hyponatremia in the setting of cirrhosis is due to impaired water
excretion resulting from persistent release of antidiuretic hormone (ADH) induced by diminished
effective circulatory volume. In cirrhotic patients whose hyponatremia fails to correct with free water
restriction, vasopressin 2 receptor antagonist is an effective alternative therapy. In this case report, we
describe a patient with hepatorenal syndrome (HRS) whose hyponatremia failed to improve with
tolvaptan and conivaptan but subsequently corrected with treatment with midodrine and octreotide.
CASE PRESENTATION: A 51-year-old female with medical history significant for alcoholic cirrhosis and
multiple admissions for hyponatremia was admitted for a serum sodium concentration of 118mmol/L
associated with a serum and urine osmolality of 254 and 519mOsm respectively. The patient’s
hyponatremia failed to improve with free water restriction. Therefore, tolvaptan (selective vasopressin-
2 receptor antagonist) was started. Despite adequate up-titration over 96 hours, her serum sodium
level remained relatively unchanged at a level of 120mmol/L. Due to the potential concern for
inadequate gastrointestinal absorption of the drug, a decision was made to change from oral tolvaptan
to intravenous conivaptan. Her serum sodium concentration minimally improved to 123mmol/L. On
hospital day 13, the patient was started on midodrine and octreotide for treatment of acute kidney
injury thought to be due to HRS, which slowly brought the patient’s serum sodium level from 122 to
132mmol/L over a five day course coinciding with the resolution of the HRS. Repeat laboratory values
revealed a stable serum sodium level of 135mmol/L nearly two weeks after initiation of the drugs.
DISCUSSION: Hyponatremia is a common medical finding in patients with cirrhosis, and is a reflection
of the severity of the underlying liver disease as well as a predictor of morbidity and mortality. As
hyponatremia in these patients is due to excess total body water resulting from increased ADH secretion
in response to the systemic vasodilation, free water restriction and vasopressin-2 receptor antagonist
are the main therapeutic options. In our patient, both therapies failed and her hyponatremia persisted
until she was started on midodrine (selective alpha-1 adrenergic agonist) and octreotide (a somatostatin
analog) for treatment of HRS, which ultimately corrected her sodium. The lack of response to the
vasopressin-2 receptor antagonists in our patient was likely due to avid renal proximal fluid reabsorption
due to decreased effective circulatory volume, thereby resulting in diminished fluid delivery to the
collecting tubule (which is the site of ADH action). The improvement in her hyponatremia with
midodrine and octreotide was likely due to increased distal fluid delivery to the collecting tubule as
reflected in the simultaneous increase in urinary output and relatively constant urinary osmolality. To
date, this is the first case report of a cirrhotic patient with hyponatremia refractory to vasopressin-2
receptor antagonists which resolved with treatment with midodrine and octreotide.
196

CANADA POSTER FINALIST - CLINICAL VIGNETTE Stephanid Dizon, MBChB
Eosinophilia – A Red Flag for Identifying Lung Malignancy
Stephanie Dizon, MBChB Secondary Authors: Christine Orr, MD, Brindusa Mocuanu, MD
INTRODUCTION: Eosinophilia is described as an elevated blood eosinophil count above
1500/microliter, often a non-specific finding with various etiologies including parasitic infections, allergic
reactions, drug reactions and neoplastic disorders (1,2,3) . It is less often associated with solid tumor
malignancies such as lung cancer, where the pathogenesis of eosinophilia is not well understood (4) .
CASE PRESENTATION: An 80 year old man presented with a three day history of progressive
generalized weakness and suffered from a fall. He described a rapid decline in carrying out normal
activities of daily living. Constitutional symptoms of anorexia and a five-pound weight loss were
apparent. His past medical history is significant for Chronic Obstructive Pulmonary Disease, angina,
hypertension, and a previous coronary bypass operation. His smoking history is equivalent to 60 packyears.
On examination he was wheezy and tachypneic, with good response to nebulized
bronchodilators. He was hemodynamically stable, afebrile with normal oxygen saturations on room
air. Respiratory examination revealed a diffuse expiratory wheeze, otherwise the remainder of the
physical exam was normal. Initial lab results revealed a significant leukocytosis of 65,600/microL, with
an eosinophil count of 27,550/microL (42%). Stools were examined for ova and parasites, Clostridium
Difficile and culture, all of which were negative.
A chest radiograph revealed a left upper lobe opacity, suspicious for an infective pneumonia or
malignancy. This was followed by a CT chest/abdomen/pelvis which confirmed a 3.9cm x 2.9cm x 3.5cm
mass in the apical segment of the left upper lobe. In addition, mediastinal lymphadenopathy, several
adjacent pulmonary nodules and a large left pleural effusion were confirmed. A hypodense liver mass
was also found suggesting a possible abscess or metastatic disease. A biopsy of the liver mass was more
feasible and confirmed poorly differentiated non-small cell lung carcinoma (NSCLC). The left pleural
effusion was subsequently drained and showed a culture-negative exudate with few atypical cells.
As he had Stage IV lung carcinoma, he was not eligible for resection nor was he a candidate for palliative
chemotherapy due to declining performance status. He was transferred to a palliative care unit for
further symptomatic treatment.
DISCUSSION: Eosinophilia in pulmonary malignancy occurs infrequently and is not well understood.
The mechanism behind eosinophilia has been postulated as a GM-CSF driven process, where GM-CSF is
produced in excess by malignant tumors, propagating leukocytosis (5) . Another case report of NSCLC
found high Interleukin-5 levels as a possible driver for eosinophil production, activation and stimulation
(3) . It is difficult to ascertain whether these eosinophilic-stimulating factors are a direct consequence of
solid tumors or a manifestation of a paraneoplastic process.
In this case, the presentation of fatigue and eosinophilia revealed itself as lung cancer with subsequent
imaging and histological analysis. In future cases of unexplained eosinophilia, further investigation for
malignancy should be sought if the risk of cancer is suspected. Furthermore, the presence of
hypereosinophilia may act as a poor prognostic indicator in those with solid tumor cancers and often
suggests metastatic disease.
197

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Andrew John Sweatt, MD
When "A Pain in the Neck" May Have Helped
Sweatt, Andrew, MD.
INTRODUCTION: Patients with fever of unknown origin (FUO) frequently endure prolonged
hospitalization, and determining an etiology requires very thorough evaluation.
CASE PRESENTATION: A 45 year-old Nepalese male immigrant presented with a three week course of
FUO. Febrile episodes occurred once daily and lasted two hours; they were associated with malaise,
myalgias, diffuse arthralgias, occasional palpitations, frontal headaches, and 10-pound weight
loss. Otherwise, complete review of systems was negative. Past medical history was only significant for
malaria (treated in 2006) and latent tuberculosis (status post nine months of isoniazid in 2009). The
patient was a non-smoker and denied use of alcohol or illicits. Since immigration to the U.S in 2008, he
worked as a chef with no trips abroad. He took no prescribed medications.
The patient had been admitted two weeks prior (for 3 days) with similar complaints and documented
fever. Workup included unrevealing CXR, negative urinalysis, blood cultures without growth, normal
head CT, and negative CSF studies. Following 24 hours without fever, he was discharged with
presumptive diagnosis of viral syndrome and given return precautions. At re-admission the patient was
found to be febrile to 39.3 degrees C, but had otherwise normal vitals. Abnormal findings on physical
exam were limited to a slightly enlarged but non-tender thyroid, bilateral shotty supraclavicular
lymphadenopathy, mild epigastric tenderness, and somewhat brisk but symmetric deep tendon
reflexes. Initial evaluation included normal basic chemistry, borderline leukocytosis with 5% reactive
lymphocytes, mild microcytic anemia, CXR without abnormalities, and unremarkable hepatic
panel. Urinalysis was unrevealing, and urine/blood cultures were without growth. ESR was elevated at
59, but extensive rheumatologic panel was negative. Iron studies were consistent with iron deficiency,
but stool was guiac-negative. Two malaria smears drawn during febrile episodes showed no
parasites. TTE was without valvular vegetations, rapid HIV was negative, and CT chest/abdomen/pelvis
was not concerning for underlying malignancy or infectious source. A week into the course the patient's
fevers persisted, he developed anterior neck pain with tenderness to palpation over the thyroid, and
sinus tachycardia emerged with heart rates of 120-130. Finally, thyroid studies were performed
revealing an undetectable TSH and elevated free T4 of 7.8 ng/dl. Subsequent thyroid ultrasound
showed a hyperemic, heterogeneous gland consistent with thyroiditis. There was no thyroid uptake on
radioactive iodine scan. Serum thyroglobulin was elevated at 241 ng/dl, but thyroglobulin and thyroid
peroxidase antibodies were undetectable. This constellation of findings was compatible with toxicphase
subacute granulomatous thyroiditis. Beta-blocker and NSAID therapy was used for supportive
management. Ultimately, the patient's fevers, tachycardia, and symptoms resolved and he was
discharged home.
DISCUSSION: This case stresses the importance of casting a wide net in the diagnosis of FUO, and
demonstrates an atypical presentation of de Quervain’s thyroiditis (initial lack of neck pain and
euthyroid appearance). The patient’s hospital course serves to remind the internist to frequently
reassess a patient with interval history/exam. Extensive and costly imaging was performed early, prior
to consideration of thyroid studies. An adept clinician understands when to allow a stable patient’s
diagnosis to better declare itself, which often leads to a cost-efficient work-up at no expense to patient
safety.
198

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Jodie A Barr, DO
Intractable New Onset Seizures and Worsening Bizarre Behavior: CONVERSION DISORDER OR IS THERE
AN ALTERNATIVE DIAGNOSIS?
Jodie A Barr, DO, Bryan Wert M.D., Cuong Doan M.D., FACP, Exempla Saint Joseph Hospital, Denver, CO
INTRODUCTION: This case describes a 20 year old male with grand mal seizures and bizarre behavior
thought to have conversion disorder. Workup revealed a rare alternative diagnosis showing the
importance of a broad differential.
CASE PRESENTATION: A 20 year old male presented to an outside hospital with a witnessed grand mal
seizure described as pill rolling and left clenched fist. He was started on Keppra without improvement
after a negative initial workup including lumbar puncture and EEG. On transfer to Exempla Saint Joseph
Hospital (ESJH) the patient was alert and intermittently exhibited purposeful movement of his left arm.
The initial admitting diagnosis was pseudo seizures versus conversion disorder. On further observation,
the patient was intermittently catatonic and at other times was agitated with choreathetosis on exam,
hyperactive reflexes throughout and decreased verbal output. He also showed autonomic instability
with tachycardia and hypertension. A repeat EEG showed right sided slowing with intermittent sharp
waves. A repeat LP showed pleocytosis with positive NMDA receptor antibody IgG in the CSF and in the
serum. He was diagnosed with anti-NMDA receptor associated encephalitis and started on IVIG and
high dose solumedrol for 5 days. He had minimal improvement and Rituxan was started with resolution
of seizures, autonomic instability, and catatonia. He continued to have behavioral outburst but
managed with Seroquel and Ativan.
DISCUSSION: This case illustrates a rare disease, anti-NMDA receptor encephalitis, in a young male
without a clear precipitant. Anti-NMDA receptor encephalitis was recently discovered in 2007, and
involves the formation of antibodies against the NR1 receptor. The frequency of this disease is
unknown, but a population based prospective study in the UK showed 4% of patients with anti-NMDA
receptor encephalitis. The majority of patients are between 19-24 years with younger patients less
likely to have associated tumors. 70% of patients present with viral prodrome with progression to
agitation, bizarre behavior, orofacial and limb dyskinesia, choreathetosis, seizure, catatonia, and
autonomic instability. Associated tumors include testicular germ cell tumors, teratoma, and Hodgkin
lymphomas. Treatment consists of immunotherapy with IVIG, steroids, and removal of the tumor if
appropriate, but there is no standard of care. Second line treatments include Rituxan and
cylophophamide. 75% of patients have full recovery, but have protracted hospital courses mostly due to
behavioral disturbance. Our case demonstrates a rare disease, anti-NMDA receptor encephalitis,
presenting with seizures and bizarre behavior, with initial diagnosis of conversion disorder. This case
shows the importance of keeping a broad differential and provides further data regarding treatment of
anti-NMDA receptor encephalitis and its associated behavioral disturbances.
199

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Ryan Borne, MD
The "Natural" Course of M. Kansasii
Ryan Borne, MD, Mark Reid, MD, Gaby Frank, MD
INTRODUCTION: In the modern era, it is uncommon to witness the natural course of certain diseases,
especially those with good response to available treatments. Chronic pulmonary disease caused by
Mycobacterium kansasii is amongst these maladies. We present a case of natural progression of
pulmonary M. kansasii infection after the patient chose a “non-traditional” treatment option.
CASE PRESENTATION: A 58-year-old female presented with progressively worsening shortness of
breath over years with rapid worsening over the previous weeks. Her medical history is notable for
progressive pulmonary disease secondary to M. kansasii diagnosed three years prior. At that time it was
recommended that she undergo antimicrobial therapy, however she declined and pursued a “natural”
approach. Nevertheless, she never consulted a licensed naturopathic provider. Upon admission, her
physical exam was notable for cachexia and bilateral pulmonary rales. Chest radiograph (CXR)
demonstrated worsening fibro-nodular densities with cavitary change. Computerized tomography (CT)
of the chest revealed similar changes with large areas of cavitation. Multiple sputum cultures grew M.
kansasii. She agreed to a 12- month, three-drug regimen consisting of rifampin, isoniazid, and
ethambutol. After one month of therapy she developed respiratory failure and was transferred to
hospice.
DISCUSSION: Alternative medicine, also known as complementary, integrative, or unconventional
medicine (CAM), is functionally defined as interventions neither taught widely in medical schools nor
available in many US hospitals. The popularity of CAM is rising, with up to 75% of patients in some
series pursuing an alternative approach as part of their health care. While there is an increasing
demand for personalized medicine, the rush to embrace new alternative therapies should be
approached with great caution and only by licensed providers. Although CAM therapies are popular,
they have not been subjected to significant rigorous studies and therefore there are not evidence-based
guidelines. Factors attracting patients to CAM include dissatisfaction with conventional medicine and a
holistic orientation to health, illness and treatment, among others. Currently, naturopathic medicine
does not offer an option for M. kansasii treatment, whereas the American Thoracic Society and
Infectious Disease Society of America consensus guidelines for the treatment of M. kansasii are based
on category A, grade II evidence level. When pulmonary M. kansasii disease is left untreated, its
mortality can reach 50%, decreasing to 2-11% when appropriate treatment is instituted.
When left to nature, M. kansasii can cause devastating illness. We emphasize the importance of
educating and understanding patients’ misconceptions on both conventional and alternative medicine
to help optimize their healthcare experience.
200

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Christopher B Estopinal,
MD
A Common Drug, an Uncommon Problem: Statin-Associated Weakness and Confusion
Christopher B Estopinal, MD, Michael J Sampognaro, MD
INTRODUCTION: Statins are well tolerated, widely prescribed medications used to control
hyperlipidemia. Although rare, cognitive side effects have been reported in drug registries and in a
small number of case reports. This case highlights the association between statins and neurocognitive
disturbances.
CASE PRESENTATION: An 80-year-old male presented to his primary care physician complaining of
lower extremity weakness, ataxia, joint pain, and scalp numbness. His past medical history was
significant for hyperlipidemia, well-controlled diabetes mellitus type 2, hypertension, factor VIII
deficiency, and mild neuroforaminal and lumbar spinal stenosis. His home medications included
atorvastatin, metformin, sitagliptin, olmesartan, and hydrochlorothiazide. He consumed approximately
two alcoholic beverages a week and was a former smoker; he intermittently used a cane when
ambulating due to left knee pain. Review of symptoms was notable for a resolving upper respiratory
infection. Physical exam was within normal limits barring mild incoordination on neurological
exam. Laboratory studies, including complete blood count, electrolytes, thyroid stimulating hormone,
vitamin B12, and creatine phosphokinase, were all within normal limits. An MRI study of the brain was
unrevealing. The patient’s statin was discontinued, and his symptoms resolved within a week.
Nine months later, the patient presented to the hospital with progressive weakness of his lower
extremities, waxing and waning confusion, hallucinations, and falls. He also reported numbness of the
extremities in a stocking-glove distribution and hypoesthesia of the scalp. A physician not aware of the
patient’s previous statin intolerance had initiated pravastatin therapy two months prior to his
presentation. The patient had discontinued his pravastatin four days prior to admission; his confusion
had resolved but none of his other symptoms had improved. Physical examination revealed decreased
proximal lower extremity strength, diffuse hyporeflexia, and a wide-based gait. Laboratory testing,
including creatine phosphokinase, was once again unrevealing. MRI studies of the head, cervical spine,
thoracic spine, and lumbar spine were within normal limits for age; carotid ultrasound revealed no
significant atherosclerosis. The patient’s symptoms completely resolved after several days of inpatient
observation and were attributed to statin intolerance. His hyperlipidemia is now managed with
colesevelam, and he has been without the reported constellation of symptoms for almost two years.
DISCUSSION: While statins are generally well tolerated, there is an emerging literature describing
statin-associated neurocognitive side effects. Our patient exhibited adverse neurocognitive reactions
associated with statins both on initial treatment and on rechallenge. The effect of statins on cognitive
function is controversial; both increased and decreased cognitive function has been associated with
their use. Proposed mechanisms for statin-associated cognitive impairment include disruption of
synaptic function through suppression of nuclear factor-[kappa]B and tumor necrosis factor as well as
modification of cell membrane composition. While not commonly associated with neurocognitive
impairment, statins should be considered during the workup of confusion in an elderly patient.
201

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Shai Feingold, DO
Subacute Inflammatory Demyelinating Polyneuropathy (SIDP) in a Patient who had Recently
Completed the hCG Diet
Shai Feingold, DO
INTRODUCTION: Acute inflammatory demyelinating polyneuropathy (AIDP) is a rare disease, affecting
1-2 people per 100,000 annually. I present a case of a patient who had recently completed the hCG diet,
which I hypothesize triggered an autoimmune reaction that led to the demyelination response.
CASE PRESENTATION: A 44-year-old man presented to a neurologist with a 5.5-week history of tingling
that began in his toes. He developed weakness and numbness in his legs that ascended to his hands and
arms. He could not rise from a chair and fell 5 times. He denied any recent illnesses, immunizations or
surgeries. Upon presentation, numbness was present up to the T6 dermatome. An EMG showed only
diffuse slowing. Deep tendon reflexes were absent. A presumptive diagnosis of inflammatory
demyelinating polyneuropathy was made and the patient was referred to this hospital for further
treatment.
CSF from lumbar puncture was normal except for a protein of 70. West Nile, VZV, HSV and enterovirus
were negative. ANA, ANCA and rheumatoid factor were also negative. MRI of the brain and c-spine
showed no abnormalities. Multiple sclerosis protein banding was negative. The patient received
400mg/kg of IVIg for 5 days. By the fifth day the patient was able to rise from a chair and flex his hips to
60 degrees (at admission he could flex to 5 degrees). Numbness had regressed to the T10 dermatome.
He was able to walk short distances with minimal instability, and was discharged on hospital day 5.
DISCUSSION: The patient had completed the hCG diet two weeks before the onset of symptoms. This
diet entails eating a 500kcal, fat-free diet for 3.5-6 weeks, accompanied by daily sublingual or
intramuscular administration of 125 IU of hCG. The diet theoretically prompts the body to develop a
hypermetabolic state, which combined with low caloric intake, forces the body to utilize its energy
reserves. I propose that the hCG acted as a foreign antigen, resulting in an immune response. In 70% of
AIDP cases, a preceding trigger, such as a viral illness, immunization or surgery is identified. This trigger
prompts both cellular and humoral immune responses that lead to an attack on the peripheral nervous
system due to molecular mimicry. Findings include a partial nerve conduction block and slowing of
conduction velocity, symmetric involvement of arms and legs in distal and proximal musculature,
reduced or absent deep tendon reflexes and increased CSF protein without pleocytosis. Treatment
includes IVIg, plasma exchange or steroids. In AIDP the nadir of symptoms occurs within 3-4 weeks of
the immunologic trigger. In this case the nadir occurred 7.5 weeks after finishing the diet, consistent
with SIDP, in which the nadir occurs 4-8 weeks after exposure. There are no reports of the hCG diet
leading to AIDP; however this case highlights a potential risk from this controversial diet.
202

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Jonathan Schwartz, MD
The Cause of a Pause is Not Always Cardiac
Jonathan G. Schwartz, M.D.1, Robert S. Schwartz, M.D.2, Joel A. Garcia, M.D.1,3,4 1Department of
Medicine, University of Colorado Denver, Aurora, Colorado, 2Minneapolis Heart Institute Foundation,
Minneapolis, Minnesota, 3Department of
INTRODUCTION: A 49 year-old previously healthy man was referred to clinic for follow-up after dual
chamber pacemaker implantation performed one week previously. The patient was on vacation one
week prior when he suddenly felt faint and lost consciousness while crossing the street with his wife. He
became unresponsive with no pulse, and his wife immediately began CPR. Shortly thereafter, the patient
developed pulses and regained consciousness. Upon EMS arrival, he again went pulseless, followed by a
generalized seizure, with subsequent return of pulses. ECG showed extreme bradycardia and sinus
arrest.
CASE PRESENTATION: Upon hospital arrival, he again developed prolonged asystole, requiring
intubation. Head CT, cardiac echo, and metabolic panel were unremarkable. A temporary pacemaker
was inserted, followed by permanent pacemaker implantation. After routine pacemaker check, the
patient returned home. Two days later, he presented to the ED with nonspecific ‘dizzy’ episodes.
Pacemaker interrogation was unremarkable, and the patient was referred to outpatient followup.
Head CT with contrast was ordered since MRI could not be performed, given the pacemaker. The
CT revealed a right temporo-parietal lesion, and MRI was required to characterize this potential
lesion. MRI was pursued, and the pacemaker mandated temporary reprogramming during brain MRI
imaging. A special, low-energy MRI protocol was used, and a cardiologist monitored the patient during
the entire MRI scan. MRI revealed a high-grade glioblastoma multiforme (GBM) in the temporal lobe.
EEG and specialist consultation suggested the cause of his lightheadedness and asystole was likely
temporal lobe seizure. The pacemaker was removed to perform functional MRI. MRI during reading
aloud, tongue tapping, and left finger tapping showed neurosurgical resection could be undertaken
without impacting key vision, speech, or motor centers. Diffusion tensor imaging showed the right optic
radiation was displaced but not interrupted by the tumor. The tumor was resected and GBM confirmed.
A permanent, MRI-compatible pacemaker was placed as he is at risk for seizures and will need
surveillance MRI imaging.
DISCUSSION: Several important clinical points are illustrated by this case. Temporal lobe seizures
causing bradycardia are rare, cause SA arrest rarely, but should be considered in cases of sinus arrest.
Secondly, brain MRI imaging can be performed safely in patients with traditional pacemakers, even if
not identified as MRI-compatible, using low energy scan sequences. Finally, functional MRI can identify
local cellular activity with overlays on anatomic images. DTI shows brain tracts by imaging water
molecule diffusion.
203

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Amy M Silverberg, MD
New Diagnosis of Sarcoidosis Presenting as Ventricular Tachycardia
Amy M Silverberg, MD Amy Silverberg, MD and Robert E. Burke, MD
INTRODUCTION: With ventricular arrhythmias related to coronary artery disease increasingly common
in the inpatient setting, physicians should remain alert to the nonischemic causes of ventricular
tachycardia and be comfortable with the role of cardiac MRI in the diagnosis of myocardial pathology.
CASE PRESENTATION: A 65 year- old man presented with three months of cough and dyspnea on
exertion that he first noted after moving to 8000 feet of elevation. He denied fever, rash, syncope,
chest pain, palpitations, orthopnea, and lower extremity edema. He reported a 50 pack-year history of
cigarette use with cessation two months prior. Physical exam revealed a well-appearing man with
normal vital signs on room air. While his heart sounds were regular, every other cardiac cycle was softer
to auscultation and was not transmitted to the radial pulse. EKG and telemetry revealed right bundle
branch block and a predominant rhythm of ventricular bigeminy as well as periods of normal sinus
rhythm intermixed with episodes of regular, monomorphic, wide-complex tachycardia. Transthoracic
echocardiogram revealed mild biventricular systolic dysfunction; there was no obstructive coronary
disease on catheterization. Moderate upper-lobe-predominant centrilobular emphysema with
mediastinal and hilar adenopathy were seen on CT of the chest. Cardiac MRI with gadolinium revealed
focal areas of delayed contrast enhancement of the anterior and basal septum as well as the basal
lateral wall.
DISCUSSION: Conduction abnormalities and ventricular arrhythmias are commonly seen by the
internist, particularly in the hospital setting. In a patient without coronary artery disease, the finding of
ventricular tachycardia (VT) mandates methodical investigation to identify other, less common
etiologies. In such cases, cardiac MRI is becoming the test of choice for investigating abnormalities of
the myocardium that predispose to VT. Although this patient was asymptomatic with regard to his VT,
the finding of hilar lymphadenopathy coupled with his MRI findings was diagnostic of cardiac sarcoidosis
(CS). CS most often involves the left ventricular myocardium and can manifest as electrical dysfunction,
including high-degree atrioventricular block, bundle-branch block, and ventricular
tachycardia. Endomyocardial biopsy is an insensitive test for CS because of patchy involvement of the
myocardium by granulomas and because the usual biopsy site is not the most common site of
granuloma formation. As a noninvasive diagnostic modality, cardiac MRI has higher specificity than PET
scan and higher sensitivity than endomyocardial biopsy.
Britton KA, Stevenson WG, Levy BD, Katz JT, Loscalzo J. The beat goes on. N Engl J Med 2010; 362:
1721-26.
Kim JS, Judson MA, Donnino R, Gold M, Cooper LT, Prystowsky EN, Prystowsky S. Cardiac
sarcoidosis. Am Heart J 2009; 157: 9-21.
Doughan AR, Williams BR. Cardiac sarcoidosis. Heart 2006; 92: 282-288.
204

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Keith Wells, MD
Stumbling Drunk With Vitamin B12 Deficiency
Keith Wells, MD, Philip Fung, MD
INTRODUCTION: Vitamin B12 deficiency often presents with fatigue and macrocytic anemia with or
without neurologic symptoms. Causes include poor dietary intake, malabsorbtive states, and
autoimmune causes. We describe a case of vitamin B12 deficiency with subacute combined
degeneration from chronic alcoholic gastritis and H. pylori infection.
CASE PRESENTATION: A 61-year-old male presented with 1 week of falling and progressive leg
weakness. The patient also described 3 months of progressive, painless numbness and tingling of his
feet bilaterally with an inability to accurately place his feet while walking. For the past year, the patient
reported decreased oral intake with prandial nausea and vomiting and a 30 pound weight loss. His only
medications were vitamins, including B12, started 1 week prior to admission at the insistence of family.
Past medical, surgical and social history were unremarkable, except heavy alcohol use with 10 shots of
vodka daily.
Initial assessment revealed a cachectic man. Neurologic exam showed decreased muscle bulk with
normal tone. Muscle strength was symmetrically diminished to 4/5 in flexors and extensors in the legs
and feet. The lower extremities had diminished sensation to light touch and vibration, an inability to
distinguish sharp and dull, and a complete loss of positional sensation of the toes and ankle. Sensation
in the upper extremities was normal. Patellar and achillies reflexes were absent. His gait was ataxic and
stamping. Laboratory analysis showed a macrocytic anemia (hemoglobin of 9.8 g/mL, MCV 106.4 fL)
with borderline low vitamin B12 levels (318 pg/mL). Subsequent lab tests revealed an elevated
homocysteine level (16 µmol/L) and an elevated methylmalonic acid level (0.30 µmol/L). An antibody
screen for anti-intrinsic factor was negative. H. pylori IgG antibodies were positive. Brain and spine MRI
imaging failed to show any acute intracranial or cord process. An upper endoscopy showed chronic
gastritis. A diagnosis of subacute combined degeneration was made with Neurology in agreement. The
patient was started on intramuscular vitamin B12 injections, a proton pump inhibitor, and triple
antibiotic therapy for H. pylori. The patient was discharged after physical therapy clearance with mildly
improved neurologic sensation.
DISCUSSION: Alcohol abuse is a prevalent problem in hospital and clinic settings. In our patient,
chronic alcoholic gastritis led to both deficient vitamin B12 intake and decreased absorption. Gastritis
reduces stomach acid production leading to decreased dissociation of vitamin B12 from food. Also,
inflammation of the gastric mucosa may lead to decreased production of intrinsic factor by parietal cells.
H. pylori has also been implicated in association with vitamin B12 deficiency with gastritis and may be
under diagnosed. Vitamin B12 supplementation may reduce neurologic damage, but outcomes are not
predictable. Our case of represents an unusual complication from the very common problem of alcohol
abuse.
205

COLORADO POSTER FINALIST - CLINICAL VIGNETTE Chi Zheng, MD
Try and Try Again, A 52 Year-Old Man Presenting with Cardiac, Renal and Hepatic Dysfunction
Chi Zheng, MD, University of Colorado School of Medicine, Aurora, CO, Rebecca Hanratty, MD, Denver
Health, Denver, CO
INTRODUCTION:
CASE PRESENTATION: A 52 year-old man was admitted with cardiac and renal failure after he
presented with one month of weight gain, lower extremity edema, dyspnea and orthopnea. His exam
revealed a S3 gallop, elevated jugular venous pressure, rales, and hepatomegaly. His serum creatinine
was 3.1 mg/dL. Serum electrolytes were normal. He had a mild macrocytic anemia. Aminotransferases
were slightly elevated around 60 U/L. Total bilirubin was 2.8 mg/dL, direct bilirubin 2.3 mg/dL, and
alkaline phosphatase and gamma-glutamyl gransferase were elevated at 444 U/L and 342 U/L,
respectively. Brain natriuretic peptide was 3054 pg/mL. Urinalysis showed 2 plus protein, without casts
or blood; proteinuria quantified to 897 mg/24 hours. Electrocardiogram showed inferior Q-waves. Mild
hepatosplenomegaly and renomegaly were found on ultrasound. Echocardiogram showed mild
concentric left ventricular hypertrophy with moderate biatrial dilation and near-normal systolic function.
Patient’s serum protein electrophoresis (SPEP) and 24-hour urinary electrophoresis (UPEP) with
immunofixation showed albumin predominance without monoclonal proteins. Serum angiotensin
converting enzyme level was normal as were serum ferritin and iron saturation. Abdominal fat pad and
liver biopsies were negative with Congo Red staining. Patient was discharged with a presumptive
diagnosis of restrictive cardiomyopathy along with congestive hepatopathy and cardiorenal
syndrome. The patient returned 6 weeks later with symptoms of worsening heart failure. His serum
calcium on admission had increased to 12.5 mg/dL with a creatinine of 5.4 mg/dL. A computed
tomography of the chest revealed a new left 8 th rib lesion; biopsy of which was consistent with a plasmacell
neoplasm. Repeat SPEP showed two faint monoclonal bands in the kappa lane. Serum kappa free
light chain was elevated at 600 mg/dL and the kappa:lamda ratio was 243. Elevated kappa light chain
was also seen on repeat UPEP. Bone marrow biopsy showed extensive involvement by a kappa light
chain-restricted plasma cell myeloma. Patient was diagnosed with multiple myeloma with light chain
deposition disease (LCDD).
DISCUSSION: Our patient presented with restrictive cardiomyopathy, renal failure and hepatomegaly.
Amyloidosis was considered but none of our patient’s biposies stained with Cong Red. LCDD has a
similar presentation with similar organ involvement as AL amyloidosis. However, monoclonal light chain
fragments, typically kappa, deposit in organs without formation of amyloid fibrils and therefore do not
stain with Congo Red. As in our patient, routine SPEP and 24-hour UPEP with immunofixation may not
demonstrate the monoclonal proteins. When amyloidosis is suspected, initial laboratory testing should
include serum immunofixation electrophoresis and measurement of serum free light chains to increase
test sensitivity for LCDD.
206

CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Shireen Mirza, MD
Chapter Winning Abstract
Shireen Mirza, MBBS Hamid Habibi, MD
INTRODUCTION: To increase awareness about: ‘bath salts’ intoxication epidemiology of use
physiological effects and symptomatology treatment
CASE PRESENTATION: HPI: 19 yr old female presented to the ED having snorted and ingested bath
salts 2 days ago followed by a 4 hour long ‘high’, succeeded by ‘jitteriness’ and inability to sleep for the
past 2 days
PMH: Depression, Substance abuse (usually ‘ecstasy’), denies recent alcohol use Meds: Prozac 20 mg
daily (NKDA) Social Hx: College student; non-smoker Physical exam: pertinent findings Vitals at ED
presentation: BP:180/62, HR:140, Temp:98.3, RR:22/min Gen: Pt awake, alert, oriented to time, place
and person, anxious, constantly shifting, talking to self, bouts of violence and bruxism HEENT: NCAT,
pupils 6 mm b/l, PERRLA, spontaneous horizontal nystagmus Abdomen: Soft, non-tender, nondistended,
BS+ Neuro: CN:normal, Motor strenth:5/5 all 4s, Sensory: normal, DTR: 4+ b/l knee jerks, 3+
b/l ankle jerks, no clonus
Labs at ED presentation: Na:138, K:3.0; Cl:104, HCO3:17, BUN:16, Se.Cr.:0.8, Anion Gap:17, Glucose:65
LFTs: normal Creatinine Kinase:965 UTox: negative for amphetamines, barbiturates, BZDs, cocaine,
opiates, PCP, cannabinoids. Blood salicylates/acetaminophen: negative
Hospital Course Day 1/ED: IV lorazepam, PO cyproheptadine in ED with decrease in SBP to 100 and HR
to 80s. Admitted to intermediate level of care with lorazepam drip. Day 2: decrease in symptoms,
normalization of HR and BP; lorazepam discontinued by evening Day 3: pt did not require symptomatic
treatment, vitals continued to be stable, anxiety subsided Day4: discharged with instruction to follow up
with PCP and to restart Prozac at 10 mg daily until seen by PCP.
DISCUSSION: ‘Bath salts’ usually contain MDPV (Methylenedioxypyrovalerone) - a relatively new
designer psychoactive drug, an NDRI (norepinephrine-dopamine reuptake inhibitor), marketed as bath
salts, plant food or household cleaners under various brand names like Vanilla Sky, Ivory Wave and
White Lightning.
Epidemiology: Emerged in Europe in mid-2000s; likely entered the US in 2009/2010. 1500 ED visits
related to exposure reported in 1st quarter of 2011 Legal status: banned by DEA on September 7th,
2011 via its emergency scheduling authority
MDPV intoxication usually manifests with a sympathomimetic toxidrome and psychological
disturbances. Possible interaction with other psychoactive medication leading to serotonin syndromelike
picture is a possibility. Rhabdomyolysis is also frequently seen Detection: currently undetectable via
routine drug screen, detectable through GC-MS screens available via specialized
laboratories. Treatment: Based on physician experiences and MoA of the drug, the following
management is recommended - benzodiazepines to control sympathetic activity and psychomotor
agitation avoid beta-blockers even at low doses to avoid unopposed alpha-adrenergic effects consider
treatment with haloperidol / ziprasidone for treatment refractory to lorazepam involve toxicology
personnel and contact a poison control center for latest facts and to report exposure.
207

CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Vasanth Kainkaryam,
MD
Azathioprine Hypersensitivity with Acute Generalized Exanthematous Pustulosis (AGEP) Mimics Septic
Shock
Vasanth Kainkaryam, MD Aimee Leonard, MD
INTRODUCTION: Acute generalized exanthematous pustulosis (AGEP) is a rare type IV drug
hypersensitivity reaction commonly associated with antibiotics such as beta-lactams and macrolides,
and less commonly with other drugs such as calcium channel blockers, vancomycin, and azathioprine. In
this case, azathioprine-induced AGEP was associated with unusually severe hemodynamic instability,
masquerading as septic shock.
CASE PRESENTATION: A 58 year old obese female with P-ANCA pulmonary-renal vasculitis was
admitted with presumed septic shock. Her medications included azathioprine, which was started 4-5
days prior to admission, and prednisone. She initially presented to an outside hospital a two day history
of malaise, decreased oral intake and urine output, orthostatic BP changes, fecal incontinence and a
rash involving her trunk and extremities. Upon transfer to our hospital, she was severely hypotensive,
with poor response to fluids, and was started on norepinephrine and transferred to the ICU.
She was felt to be in septic shock given her immunocompromised status, hemodynamic instability,
urinalysis concerning for urosepsis, transaminitis, and CXR concerning for possible pneumonia. An
extensive workup was performed, and she was empirically treated with vancomycin and meropenem;
acyclovir was added to cover for suspected disseminated varicella. Her shock-like symptoms and renal
function acutely worsened and she eventually required two vasopressors.
Her skin eruption progressed during her hospitalization and was characterized by monomorphous
micropustules on an erythematous base. Dermatology was consulted and a punch biopsy showed
intracorneal and subcorneal pustules, with the dermis containing superficial perivascular infiltration of
lymphocytes, eosinophils and neutrophils consistent with AGEP. The remainder of her workup including
blood and urine cultures, viral cultures and DFA, lumbar puncture and bronchoscopy with respiratory
DFA was negative. Given the skin biopsy findings of AGEP and the negative sepsis workup, her
presentation was felt to reflect a severe life-threatening hypersensitivity reaction to azathioprine. Her
broad spectrum antibiotic coverage was discontinued and she had a full recovery off the offending drug.
DISCUSSION: AGEP is a rare hypersensitivity reaction, characterized by non-follicular sterile pustular
lesions with an erythematous and edematous base, often presenting with pyrexia and neutrophilic
leukocytosis. Reported incidence is 1-5 per million per year. Commonly reported agents associated
with AGEP include antibiotics (particularly beta-lactams, macrolides, and vancomycin), viral infections,
and mercury. The development of symptoms is usually acute, within 2-5 days of exposure with
spontaneous resolution in 1-2 weeks. A mild transaminitis and acute kidney injury may also be
present. While AGEP can resemble sepsis as has been reported with a case of ceftriaxone, severe
hemodynamic derangement appears rare. In this case, azathioprine-induced AGEP was easily
misdiagnosed initially as septic shock. Given the self-limiting nature of the disease, discontinuation of
the offending agent and hemodynamic support are the main goals of care, with no clear role for
steroids. Increased awareness of this condition is crucial for physicians given the associations with many
medications, and potential for significant hemodynamic compromise.
208

CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Zhongzhen Li, MD
An Unusual and Curable Pancreatic Malignant Mass
Zhongzhen Li, MD, Nadiya Vasdani BSc, Eddy Castillo MD. Dept. of Medicine, St. Vincent’s Medical
Center, Bridgeport, CT
INTRODUCTION: Primary pancreatic lymphoma (PPL) is a rare disease, accounting for only 1% of
extranodal lymphomas and 0.5% of all pancreatic masses. Differentiating PPL from the more common
adnocarcinoma is difficult and important since the treatment and prognosis differ considerably.
CASE PRESENTATION: A 43-year-old man presented with one-week duration of RUQ abdominal pain,
nausea, weight loss and an epigastric mass. He had presented six month earlier with similar symptoms
without weight loss or mass, all of which resolved after esomeprazole treatment. Physical examination
revealed epigastric tenderness and a 6cm×3cm epigastric mass without peripheral lymphadenopathy or
hepatosplenomegaly. Laboratory data showed normal CBC, serum transaminase and CA19-9 level;
elevated amylase of 297, lipase of 264. CT scan of the abdomen showed a 14.3cm pancreatic head mass
that obliterated fat planes between the stomach, duodenum and colon with mass effect on the IVC;
scattered enlarged mesenteric and retroperitoneal lymph nodes. Endoscopic ultrasound (EUS) revealed
a pancreatic head lesion causing extrinsic compression of the duodenum with ulceration. EUS guided
fine needle aspiration (FNA) of the mass and duodenal mucosa revealed large atypical lymphoid cells
positive for pan B-cells markers: CD20 and PAX5 with co-express of CD10, BCL-2, BCL-6 on
immunohistochemstry staining. Flow cytometry analysis also demonstrates a monoclonal Kappa CD10
positive large B-cell population. Bone marrow biopsy was normal. The above findings were indicative a
diagnosis of PPL. Repeated CT 1-month after R-CHOP chemotherapy (Rituxan, Cyclophosphamide,
Hydroxydaunorubicin, Oncovin and Prednisone) showed resolution of the mass with only hazy residual
infiltration of the fat in the region anterior to the pancreatic head.
DISCUSSION: PPL shows a slight male predominance and is usually seen in the 5 th or 6 th decade of life.
Its vague symptoms and the most common location being in the pancreatic head make it difficult to
differentiate PPL from the more common pancreatic adenocarcinoma without biopsy. Behrns' diagnostic
criteria for PPL includes: no lymph node enlargement of superficial or mediastinal lymph nodes; a
normal leukocyte count in the peripheral blood; main mass in the pancreas with lymph nodal
involvement confined to the peripancreatic region, no hepatic or splenic involvement. This case
highlights several important points. A large pancreatic mass without significant dilatation of the main
pancreatic duct, invasion to the large vessels and obstructive jaundice and normal CA19-9 suggest a
diagnosis of PPL over adenocarcinoma. EUS-FNA is a reliable and cost-effective method for pancreatic
mass sampling. We successfully diagnosed the patient with EUS-FNA biopsy which avoids him from
invasive diagnosis and therapy. Chemotherapy is the treatment of choice for PPL.
209

CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Muhammad Adnan
Sohail, MBBS
A Case Of May-thurner Syndrome Associated With Phlegmasia Cerulea Dolens.
Muhammad Adnan Sohail, MBBS Last author: David Roer, MD
INTRODUCTION: Phlegmasia alba dolens is a spectrum of disease related to Deep venous thrombosis.
It is a sudden onset of occlusion of deep venous system. The leg turns edematous and white (alba). As
the superficial venous supply occludes, it affects the arterial flow and called plegmasia cerulea dolens.
May-Thurner syndrome is a rare condition in which blood clots occur in the iliofemoral vein due to
compression of the common venous outflow tract of the left lower extremity.
CASE PRESENTATION: A 37-year-old Woman with a past medical history of depression, anxiety and
migraine, who presented to emergency complaining of severe left leg pain and swelling which is sudden
in onset. Pain is 10/10, worse with walking extends from calf and to distal leg. She was hemodynamically
stable. Her left extremity was pale, white, swollen and dorsalis pedis pulse was diminished. Her
laboratory data at admission showed lactic acid of 8, D-dimer of 4300 with normal hematology and
metabolic profile. Her US of lower extremity showed occlusive deep venous thrombosis extending from
the left external iliac vein into the left popliteal vein. Venography showed a cast of thrombus filling in
the left deep system from the common femoral vein to the mid popliteal vein. Diffuse left iliac vein
stricture likely the etiology of the patient's DVT and consistent with May-Thurner syndrome. Pt has signs
of left leg ischemia. An immediate thrombectomy was performed with a stent placement. CT chest did
not show PE and CT abd/pelvis did not reveal any mass. Coagulation profile did not show any
abnormality and factor V and antithrombin 3 mutation was negative. Pts left leg pain immediately got
better after thrombectomy with stenting and her pulse were full and color skin turned red. Pt was
started on anticoagulation and discharged on warfarin.
DISCUSSION: This is the rare presentation of deep venous thrombosis, which occluded venous system
to the extent that it caused obstruction of blood supply to lower limb. Fabricus Hildanus first described
this entity in the 16th century. Precipitating factors include malignancy, femoral vein catheterization,
heparin-induced thrombocytopenia, antiphospholipid antibody syndrome. In May-Thurner syndrome,
there is compression of the left common iliac vein by the overlying right common iliac artery. It occurs
only in left leg. This is the first case of May-Thurner syndrome causing plegmasia cerulea dolens. Prompt
diagnosis and treatment initiation are paramount in order to prevent progression to venous gangrene
and the need for amputation and possible death of the patient who presents with this condition.
210

DELAWARE POSTER FINALIST - CLINICAL VIGNETTE Jennifer A Hurd, MD
SUGAR (Sulfonylurea Use Gone AwRy)
Jennifer A Hurd, MD-Associate; Vinay Maheshwari M.D., Christiana Care Health Systems.
INTRODUCTION: CASE PRESENTATION: A 45 year-old man with a history of diabetes mellitus, endstage
renal disease on hemodialysis, and liver disease presented to the emergency department
complaining of sweats, lightheadedness, and episodes of lethargy with slurred speech. His serum
glucose was discovered to only be 20mg/dl. He was immediately administered multiple ampules of 50%
dextrose (D50) solution and initiated on dextrose 5% continuous infusion. Repeat glucose testing was >
100mg/dl, but subsequent testing revealed repeated severe hypoglycemia requiring treatment. The
patient’s course then entered a cycle of responding to glucose- containing fluid followed by a severe
drop in blood sugar 1 hour later. Supplementation with 10% dextrose fluid was then initiated without
overall improvement in the dramatic fluctuations in blood sugar measurements.
After a number of hours, the patient finally admitted to ingestion of 8mg of glimepiride to treat a
random home blood glucose measurement of >400mg/dl. Once the etiology was discovered,
formulation of a more effective treatment plan was required. This was more imperative given his poor
response to glucose supplementation, as well as the prolonged half- life of glimepiride in the setting of
renal failure. He received a bolus dose of octreotide followed by a continuous infusion at 25mcg/hr. His
blood glucose values immediately began to improve and no further hypoglycemia was observed.
DISCUSSION: This case highlights the limitation of dextrose as monotherapy in sulfonylurea
overdose. The mechanism of action of sulfonylureas lies in their effects on the potassium channels of
the pancreatic beta cell membranes resulting in increased insulin release. As a class, they are hepatically
metabolized and some, including glimepiride, have renally excreted active metabolites. Glucose
administration is indicated overdose; however, glucose may also stimulate further insulin secretion
resulting in persistent hypoglycemia. Multiple case reports exist in the literature regarding using
ocreotide as an adjunctive therapy in sulfonylurea overdose. 1 Octreotide is a somatostatin analog
whose proposed mechanism of action is via inhibition of the voltage-gated channels on pancreatic beta
cells, causing a G protein-mediated decrease in calcium influx, which in turn decreases insulin
secretion. 2 Doses can range between 50 to 150 mcg intramuscularly or subcutaneously every 6 hours or
be delivered by continuous infusions. Following adjunctive therapy with octreotide, our patient’s cyclic
hypoglycemia resolved, allowing transfer to a lower level of care and a shorter hospital stay. Octreotide
therapy should be considered in patients who present with sulfonylurea overdose, particularly if
refractory to glucose administration.
Dougherty, Patrick and Klein-Schwartz, Wendy. “Octreotide’s Role in the Management of Sulfonylureainduced
Hypoglycemia.” J. Med. Toxicol. 2010. 6:199-206.
Fasano, CJ. et al. “Comparison of Octreotide and standard therapy versus standard therapy alone for
the treatment of Sulfonylurea-induced hypoglycemia.” Ann. Emerg. Med. 2008. 51(4): 400-406.
211

DELAWARE POSTER FINALIST - CLINICAL VIGNETTE Christopher J
Prendergast, MD
Ironing Out a Potentially Grave Cause of Fatigue
Christopher J Prendergast MD, Associate, and Allison Buonocore, MD, FACP, FAAP, Christiana Care
Health System, Newark, DE
INTRODUCTION: Fatigue is common complaint. Routine laboratory investigations are rarely of help.
This case illustrates that in a young patient with a clear change in energy level, targeted laboratory tests
can be diagnostic of several conditions warranting treatment.
CASE PRESENTATION: A 17 year-old Hispanic female with history of vitiligo presented with gradually
worsening fatigue and sleepiness, before which she had been quite active. Her remaining past medical
history was notable only for allergic rhinitis. Menses began at age 12 and were reportedly normal.
Physical examination was normal except for vitiligo. Laboratories studies revealed normal basic
metabolic panel, CBC, liver functions, vitamin B12, and peripheral blood smear. Thyroid stimulating
hormone (TSH) was markedly low at

[1] Edwards CQ, Kelly TM, Ellwein G, Kushner JP. Thyroid disease in hemochromatosis. Increased incidence in homozygous men. Arch Intern
Med. 1983 Oct;143(10):1890-3. PubMed PMID: 6625774.[2] Van de Vyver FL, Blockx PP, Abs RE, Van den Bogaert WG, Bekaert JL. Serum ferritin
levels in hyperthyroidism. Ann Intern Med. 1982 Dec;97(6):930-1. PubMed PMID: 7149500.
213

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Lara M Paraskos, MD
Chapter Winning Abstract A Case of Massive Splenomegaly
Lara Paraskos, MD
INTRODUCTION: Gaucher’s Disease is a lysosomal storage disease where a deficiency in the
glucocerebrosidase enzyme causes glucocerebroside to accumulate in the bone marrow, liver, spleen
and lungs. Common presenting symptoms include anemia, thrombocytopenia, osteopenia, growth
retardation, and hepatosplenomegaly. Type 1, the nonneuronopathic form, more common in Ashkenazi
Jewish heritage with a disease frequency of 1 per 855. Types 2 and 3 are the neuronopathic forms that
involve the CNS. Family and ethnic history is vital in considering the diagnosis which is confirmed with
bone marrow or liver biopsy showing macrophages with the classic abundant crinkled tissue-paper
cytoplasm as in this case.
CASE PRESENTATION:: Obtaining an adequate family history with focus on ethnic background plays an
important role in the recognition of genetic diseases. Although Gaucher’s disease is an uncommon
condition in an adult population; including this type of conditions in the differential diagnosis may
improve early diagnosis, adequate treatment and overall prognosis. Early recognition in this patient may
have prevented unnecessary and potentially harmful workup.
214

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Ricardo Correa, MD
“i Am Different From The Rest!” An Interest Case Of Hormonal Control.
Ricardo Correa, MD, Melany Castillo, Ana Sandoval, Alejandro Ayala
INTRODUCTION: Kallmann's syndrome is characterized by hypogonadotropic hypogonadism and one
or more non-gonadal congenital abnormality, including anosmia, red-green color blindness, midline
facial abnormalities such as cleft palate, urogenital tract abnormalities, synkinesis (mirror movements)
and neurosensory hearing loss.
CASE PRESENTATION: We present a 28-year-old gentleman who was first diagnosed with testosterone
deficiency approximately at 12 years old in Cuba. He was treated with "a cycle of testosterone" but then
it was discontinued by his doctors. When he was 17, he was told that one of his testicles had not
descended into the scrotum while being examined for a military service. He then immigrated to United
States in 2010, where his PCP noted that he was hypogonadic and then referred to the endocrinology
clinic.
At his first visit, he denies any history of olfactory problems, although, upon further questioning, he
clearly states that he has difficulty smelling different substances, which was clear during physical
examination where he was unable to distinguish the smell of coffee, alcohol, perfume or chocolate. He
also mentioned that he has a 21 and a 4 year-old nephew that also appeared to be hypogonadic and
have cryptorchidism and synkinesis.
The patient had not developed secondary sexual male characteristics except for the mild presence of
terminal hair in the pubic area and he had a fine voice with eunuchoid habitus. Imaging studies as well
as test were unremarkable, except for low serum levels of FSH, LH, HCG, total testosterone and free
testosterone indicating severe hypogonadism. The patient was stared in low dose of testosterone, with
further counseling of fertility.
DISCUSSION: More recently, genetic testing has provided a more detailed understanding of the
disease. Studies of patients with Kallmann's syndrome have demonstrated mutations of several genes
that encode cell surface adhesion molecules or their receptors required for the migration of GnRHsecreting
neurons from the olfactory placode into the brain and then into the hypothalamus. These
genes include KAL1 , fibroblast growth factor receptor 1 (also called KAL2) , prokineticin-2 (PROK2) and
its receptor (PROKR-2).
These mutations account for less than 50% of the cases. Therefore, identifying new patients with the
disease that do not have previously described mutations may shed a new light into the pathophysiology
of this rare disorder and bring upon further understanding of the mechanism that govern gonadal
function.
215

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Ricardo Correa, MD
Parasite In The Brain: An Unusual Case Of Severe Malaria
Ricardo Correa, MD, Ashley Britel, Hoang Minh, Libin Wang
INTRODUCTION: Cerebral malaria is an encephalopathy that presents with impaired consciousness,
delirium, and/or seizures; focal neurologic signs are unusual. The onset may be gradual or sudden
following a convulsion. Although the pattern of cerebral malaria in children has been extensively
reported, relatively little is known of the clinical features of cerebral malaria in adults.
CASE PRESENTATION: 61 year old Haitian male who came directly from Miami International Airport
presented with 15 day history of subjective fever, weakness, fatigue, shortness of breath, palpitation,
nausea, cough with yellow sputum and chest discomfort.
He had a past medical history of hypertension, diabetes mellitus, hyperlipidemia, diastolic heart failure
with an EF of 40% and breast cancer in 2002 (which was treated with mastectomy, chemotherapy until
2005 and Femara until 2010. Also, he was hospitalized with pneumonia in March 2010 treated with
ceftriaxone and azithromycin; these two medications plus Femara resulted in acute liver failure
requiring a month’s stay in the intensive care unit.
On the physical exam, the patient was in mild distress, afebrile but tachypneic with rhales bilaterally; all
other systems were within normal limits.
On hospital day 1, the patient became febrile, thus´ pancultures were drawn and was started on
levofloxacin for the possibility of a community acquire pneumonia. In addition, a peripheral blood smear
and dengue serology were ordered because of the possibility of malaria or dengue (patient had recent
travel to Haiti) and the presence of dark urine. On hospital day 3, the patient developed altered mental
status. The Glasgow scale of the patient went from 15/15 to 7-8/15 and he was transfered to the MICU.
Dengue serology came back negative but the thin and thick smear for malaria was positive and reported
P.falciparum with 2% of parasitemia. He was treated with artesumate and then switched to doxycicline
for 7 days. The patient recovered and was discharged home without any sequelae or complications from
his illness.
DISCUSSION: The criteria for making the diagnosis of cerebral malaria include: Glasgow coma score less
than 11 in adults, P. falciparum parasitemia and no other identifiable cause of coma (e.g.,
hypoglycemia, meningitis, or a post-ictal state). The most common symptoms at presentation are fever,
general malaise, cough, myalgia, vomiting, headache, hepatomegaly, and splenomegaly. The definitively
treatment is based on two major classes of drugs available in parenteral form: the cinchona alkaloids
and the artemisinin derivatives.
The lesson learned from this case is that one has to keep in mind the diagnosis of cerebral malaria if a
patient has had recent travel to an endemic area, despite the absence of typical symptoms of malaria as
in our unusual case. Early detection leads to early treatment which is critical in preventing progression
to severe, life threatening disease
216

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE David Franco, MD
I Smell A Rat: A Case Report And Literature Review Of Paradoxical Thrombosis And Hemophilia In A
Patient With Brodifacoum Toxicity.
David Franco, MD George Everett, M.D., F.A.C.P. Manoucher Manoucheri M.D., F.A.C.P.
INTRODUCTION: Brodifacoum poisoning occurs as a result of ingestion of rodenticide compounds. It
acts as a superwarfarin, inhibiting an enzyme vital for vitamin K recycling, vitamin K epoxide reductase,
in an irreversible fashion much like warfarin but with a much longer half life.
CASE PRESENTATION: A 48 year-old female patient reported four days of mild dyspnea, dry cough,
bilateral popliteal fossae pain, and diffuse upper abdominal pain. Her past medical history was
significant for an unspecified psychiatric disorder and pain seeking behavior. She had no history of liver
disease, alcohol or illicit substance abuse. Initial physical exam was remarkable only for mildly pale
conjunctivae and mild tenderness of the left side of the abdomen and in the left popliteal fossa. CBC was
normal. Complete metabolic panel (CMP) was only positive for an aspartate aminotransferase of 56.
Prothrombin time (PT) was above 100 seconds, partial thromboplastin (PTT) time was above 200
seconds and international normalized ratio (INR) was reported as above 12.0. Urinalysis was positive for
2+ hematuria and mild leukocyturia. Venous Doppler ultrasound of lower extremities demonstrated a
thrombus in the left popliteal vein. CT scan of the abdomen demonstrated terminal ileum thickening
probably related to transmural hematoma and fecal occult blood test was positive. A full anticoagulant
work up showed critical reduction of vitamin K dependant factors II, VII, IX and X. PT and PTT corrected
with mixing studies proving factor deficiency as the cause of the coagulopathy. Lupus anticoagulant
studies were negative. Given these findings, vitamin K antagonist toxicity was suspected and confirmed
with an anticoagulant poison panel positive for Brodifacoum, a commonly encountered substance in
rodenticides. The patient was hospitalized and successfully treated with fresh frozen plasma,
cryoprecipitate and parenteral vitamin K supplementation as adjunctive therapy.
DISCUSSION: We postulate that the cause of the thrombotic phenomenae was related to the rapid
depletion of proteins C and S within the initial period of toxicity and therefore a transient thrombophilia
that was followed by a tendency for hemorrhage. In conclusion, paradoxical thrombosis and hemophilia
should raise the suspicion for superwarfarin toxicity in the appropriate clinical setting. Further studies
are required to define the optimal management of these patients.
217

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Morganna L Freeman-Keller,
DO
Massive Enoxaparin Overdose: What Are the Therapeutic Options?
Morganna Freeman, DO, PGY3 (Internal Medicine Residency Program, Shands at the University of
Florida) and Marc Zumberg, MD, FACP (Division of Hematology, Department of Internal Medicine at the
University of Florida)
INTRODUCTION:Enoxaparin (low-molecular weight heparin, LMWH) has seen increasing use as both a
therapeutic and prophylactic anticoagulant, however its activity against thrombin and activated Factor X
makes its reversibility problematic, as opposed to heparin or warfarin. As a result, management of
LMWH overdose presents a challenge for internists and hematologists alike. Here, we present the
diagnostic and therapeutic dilemmas presented with a massive intentional overdose of enoxaparin.
CASE PRESENTATION: A 34 year old female with a history of bipolar disorder was admitted to our
intensive care unit after being found at home following a suicide attempt; empty bottles of Xanax and
Fioricet were found at the bedside. She also had a history of pulmonary embolism linked to
heterozygous Factor V Leiden mutation and had been prescribed enoxaparin 80mg subcutaneously BID.
She had recently filled her prescription, and twenty empty enoxaparin syringes were also found at the
scene. She was intubated for unresponsiveness and brought to our hospital for further treatment.
On initial exam the patient had wrist lacerations without active bleeding and multiple abdominal
ecchymoses at the injection sites. Initial labs showed acetaminophen level of 16, INR of 1.3, protime of
16.4, PTT of 98, LWMH level of 8 (normal range 0.8-1.2) and normal liver function tests. Urine drug
screen was positive for benzodiazepines and barbiturates. She was treated with n-acetylcysteine for
acetaminophen overdose, and Hematology consultants recommended serial monitoring of LMWH level,
complete blood counts (CBCs) and neuro examinations. Literature search yielded no proven treatment
for such a large overdose of enoxaparin, with protamine reportedly only marginally effective. Factor VII
was considered, but given its prothrombotic effect and her history of PE it was decided to delay this
treatment until evidence of bleeding manifested.
Twenty four hours into admission, she became hypotensive and had a Hematocrit drop from 39% to
23%. CT of the abdomen showed large, bilateral retroperitoneal hematomas with active bleeding near
the common femoral artery. Vascular Surgery was consulted but no surgical intervention was staged.
She received 6 units of packed red blood cells, 50mg of protamine, and three doses of Factor VII.
Subsequent to this treatment, no further bleeding episodes occurred and she was successfully
extubated twenty four hours later. It took sixty hours for her LMWH level to normalize.
DISCUSSION: The management of LMWH overdose is not well-documented in the literature; there is no
effective reversal agent, and hematology sources cite the success of protamine as less than 60 percent.
Currently no treatment guidelines exist, and unfortunately clinicians must rely on a “watch and wait”
approach to therapy as bleeding complications vary. With the increasing use of LMWH, however,
clinicians must be mindful of overdose, as the lack of a proven reversal agent continues to pose
management challenges.
218

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Shenoda Gadalla, MD
A Devastating Birth Mark
Shenoda Gadalla, MD Second Author: Joao Braghiroli, MD Third Author: Venkat Kalindindi, MD
INTRODUCTION:Congenital spina bifida oculta is associated with distortion of the spinal cord, the
spinal nerve roots or both. The effect of the anomalies is evident as neurological abnormalities of the
lower limbs and neuropathic bladder dysfunction. Adult patients with spina bifida may present with
urinary symptoms as the sole initial complaint and lack obvious neurological abnormalities, but usually a
tuft of hair is evident on the lower back. Renal scaring and renal failure are secondary to neurogenic
bladder in patients with spina bifida.
CASE PRESENTATION: This is a 30-year-old male originally from British Guyana without significant
medical history who presented with a one month history of worsening bilateral lower extremity edema
and confusion. He reported incontinence during childhood that resolved by the age of 13 and he
recently noted a decrease in his urine output. He denied dysuria, hematuria, flank pain, fever, chills,
nausea or vomiting. He also denied recent sore throat, skin infection or medication usage.
On physical examination, vitals were remarkable for an elevated blood pressure of 208/129. Skin exam
was consistent with the presence of a tuft of hair on the lower back which the patient identified as a
birthmark. Lower extremities had 2+ non-pitting edema and uremic frost between his toes bilaterally.
The patient was somnolent, but oriented to place and person, without focal neurological deficit.
Labs showed hemoglobin 7.2, platelet 113, potassium of 5.3, bicarbonate 14, albumin 3.9, BNP 6429,
BUN >140, creatinine > 20, amylase 829 , lipase 12620.
A computerized tomography of the abdomen and pelvis without contrast revealed an edematous
pancreas with stranding of the peripancreatic fat and atrophic kidneys. The renal ultrasound showed a
severely atrophic left kidney and was unable to visualize the right kidney secondary to advanced
atrophy. Voiding cystourethrogram showed large postvoid urinary bladder residual and mildly
trabeculated urinary bladder consistent with neurogenic bladder. The patient was admitted to intensive
care unit and hemodialysis was initiated. Considering the diagnosis of neurogenic bladder, the patient is
ultimately a poor candidate for a renal transplant.
DISCUSSION: Renal damage and renal failure are among the most severe complications of spina bifida.
An early diagnosis and comprehensive treatment strategy should be applied in order to result in minimal
renal scaring. The majority of patients are able to control their urinary sphincter by the time they start
elementary school. To obtain such results, it is mandatory to treat detrusor overactivity from birth
onward since upper urinary tract changes predominantly start in the first months of life. Patients with
spina bifida should be treated from birth by sterile intermittent catheterization and pharmacological
suppression of detrusor overactivity to prevent renal failure secondary to renal scaring.
219

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Natallia Maroz, MD
Stay Hydrated” or Danger of Social Polydipsia
Maroz Natallia, Ejaz Ahsan Division of Nephrology, Hypertension and Renal Transplantation University of
Florida, Gainesville.
INTRODUCTION:Popularizing of health maintenance related habits via the social media by nonmedical
professionals can lead to misuse of potentially beneficial recommendations. Frequently used "Stay
hydrated" message, encouraging people to consume fluids in excess to their natural thirst, can lead to
several water-balance abnormalities.
CASE PRESENTATION: 53 year old woman was referred to nephrology clinic for the second opinion on
persistent hydronephrosis. She had a history of asthma, hysterectomy and recent diagnosis of diabetes
mellitus (DM) type II. Her only medication was Sitagliptan 50 mg daily for the last 2 years and family
history was significant for DM type 2.
12 months prior to her presentation patient experienced mild bilateral flank pain. As a part of her
evaluation computed tomography (CT) of the abdomen was completed and revealed presence of
moderate bilateral hydronephrosis and hydroureters. Her renal function was normal. Lack of health
insurance delayed urological evaluation for 6 months. Repeated CT and intravenous pyelogram
confirmed persistent moderate hydronephrosis on the right, and mild on the left. The cystoscopy was
unremarkable.
Patient underwent placement of right ureteral stent. Unfortunately, she experienced post-procedural
pain and no improvement in hydronephrosis was noted on the repeated CT scan in 2 months. Ureteral
stent was removed and patient was referred to the gynecologist. She underwent exploratory
laparoscopy with lysis of adhesions and right oophorectomy. One month later CT was repeated and
revealed unchanged degree of bilateral hydronephrosis. At that point, patient was referred to the
tertiary center for further management.
Upon review of systems patient reported to drink 4.5-5.5 liters of fluids daily for the last 3 years as “All
my friends do so to stay healthy”. Her physical examination and laboratory data were unremarkable.
Her HBA1C was 6.3, serum sodium 139 mg/dL and urine specific gravity 1.019.
Patient was suspected to have non-obstructive fullness in urine excretory system, due to mismatch of its
capacity to excessive production of urine. She was advised to decrease intake of fluids to no more than 2
liters per day and return for follow-up in 6 weeks.
The repeated kidney ultrasound at the time of follow-up revealed normal sized kidneys bilaterally and
complete resolution of hydronephrosis. Patient was discharged from the nephrology clinic with
recommendations to drink by thirst.
DISCUSSION: Although non-obstructive hydronephrosis due to polydipsia was recognized at least since
Oslers's description of several cases, majority of physicians are not well aware about this condition. This
unfortunately can lead to unnecessary invasive and morbid medical interventions and significant healthrelated
cost. Considering the sequel of exaggerated social habits promoted by modern media is
important part of practicing medicine in 21st century.
220

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Laurie Ann Ramrattan, MD
Medical decision: “Do no harm” or “better safe than sorry”? Mycophenolate Mofetil used in a lupus
patient with diffuse alveolar hemorrhage.
Laurie Ann Ramrattan, MD GS Kaeley, MBBS, MRCP, C Pappa, MD.
INTRODUCTION: Five million people worldwide suffer from Systemic Lupus Erythematosus (SLE), a
complex disease with potentially fatal complications. Early mortality in SLE has been improved with the
use of cytotoxic drugs. On the other hand, infections attributed predominantly to immunosuppressant
medications account for approximately 25% of all deaths. Therefore judicious use of medications that
balances the risks and benefits of an aggressive treatment is needed.
CASE PRESENTATION: A 26-year-old female presented with a two-week history of fever and dyspnea.
She also reported arthralgias, photosensitive rash, hair loss and Raynaud’s phenomenon of the same
duration. On examination she was found to be febrile and tachycardic. Significant labs showed:
hemoglobin of 6.8 g/dl, white cell count of 2.2 x 10 9 /l and a creatinine of 0.77 mg/dl. Chest radiograph
indicated reticulonodular opacifications involving the lower lung fields and CT chest revealed diffuse
interstitial and parenchymal opacities. Bronchoscopy revealed bright red blood due to diffuse alveolar
hemorrhage (DAH). Bronchoalveolar lavage cultures were negative. Her constellation of symptoms was
suggestive of SLE which was confirmed by the positive serology: ANA >1:1280, elevated double stranded
DNA >300 IU/ml, anti- Smith >8 AI, RNP>8 AI and anti Ro>8 AI. Complement levels were depressed (C3-
26 and C4-5.1). Urinalysis was benign. ANCA, anti-GBM and antiphospholipid antibodies were negative.
The patient was diagnosed with DAH secondary to SLE and daily intravenous 1 gram methylprednisolone
was given for 3 days, followed by oral prednisone 60mg daily. Cyclophosphamide was initially
considered as a steroid sparing treatment, however due to the rapid improvement of symptoms,
mycophenolate mofetil (MMF) was felt to be a safer choice. Ten months later prednisone was
successfully tapered to 5 mg daily and the patient remained asymptomatic on MMF without evidence of
recurrence of pulmonary hemorrhage.
DISCUSSION: DAH is a rare and potentially catastrophic complication of SLE. It usually occurs in
patients with a known history of SLE and active extrapulmonary disease. Early aggressive treatment with
high dose corticosteroids and cyclophosphamide is considered to be the standard of care and has
significantly decreased mortality. MMF in addition to steroids has not been used for induction therapy
of DAH in SLE. MMF causes less morbidity and mortality when compared to cyclophosphamide. Our
patient showed remarkable improvement even before MMF was initiated; however addition of a
steroid-sparing agent was necessary to prevent a possible fatal recurrence of pulmonary hemorrhage.
Our case is unique in that our patient presented with DAH as the first presenting symptom of lupus and
that the induction of remission and maintenance was accomplished with less aggressive treatment.
221

FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Anusha Vallurupalli, MBBS
Diplopia: Not always a benign symptom
Anusha Vallurupalli, MBBS Second Author: Roja Harish-Pondicherry, MD Faculty Author: Nam H Dang,
MD, PHD
INTRODUCTION: Diplopia, commonly known as double vision, is usually a result of impaired extra
ocular muscle dysfunction. As an example, the sixth cranial nerve innervates lateral rectus muscle of the
eye and aids in abduction; palsy of this nerve can result in impaired abduction of the affected eye and
resultant diplopia.
CASE PRESENTATION: A 42 year old Caucasian male with past medical history of chronic low back
pain, and hypertension presented with a 4-day history of double vision. He noted diplopia when looking
straight ahead which worsened when looking to the far right. He denied double vision when looking to
the left or when covering either eye. Complete review of systems was negative aside from the diplopia
and mild headaches. Physical examination was significant for partial lateral rectus palsy of the right eye
with failure to abduct the eye when looking far right.
Given his young age and absence of other neurologic symptoms, malignancy was suspected and workup
was pursued. Chest X-ray revealed a paratracheal mass that was demonstrated on chest CT as
conglomerate anterior mediastinal mass concerning for lymphoma. CT-guided biopsy of the mass was
positive for Acute T-cell lymphoblastic lymphoma. MRI of the brain and CSF analysis were negative for
CNS involvement. PET scan was positive for FGD- avid conglomerate anterior mediastinal mass, right
supra-clavicular, and retro-crural lymph node and 1.6 cm pleural based nodule. Bone marrow biopsy
was negative for lymphoma. He was initiated on Hyper-CVAD (Cytoxan, Adriamycin, Vincristine and
Dexamethasone) alternating with high dose Methotrexate. He is receiving CNS prophylaxis with
intrathecal methotrexate and Cytarabine. By the second cycle of chemotherapy he noted improvement
in double vision, with improved sixth cranial nerve palsy on physical examination. Chest X-ray confirmed
a decrease in the size of the mediastinal mass. At subsequent visits, the cranial nerve palsy had
completely resolved with continued regression of the mediastinal mass.
DISCUSSION: Isolated sixth cranial nerve palsy is usually seen in elderly population with increased
incidence in 5 th decade of life. Microvascular occlusion of the arterioles supplying the nerve from
diabetes or hypertension is the common cause. These palsies are usually acute in onset, present with
complete palsy, and resolve in 2-3 months of treatment of the underlying condition. A higher index of
suspicion must be maintained in younger adults with isolated partial sixth cranial nerve palsy, as
malignancy, infectious processes and autoimmune diseases such as myasthenia gravis, multiple
sclerosis, sarcoidosis and giant cell arteritis may be identified. To our knowledge, this is the first
description of isolated partial sixth nerve palsy associated with T lymphoblastic lymphoma without
primary Central nervous system involvement.
222

GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Mary T Oluwatimilehin, MD
Chapter Winning Abstract - A Rare Case of an Inferior Vena Cava in a Young Woman
Mary Nwoke, Mark Bradshaw, Justin Rafael, Balsam ElHammali, Chinedu Ivonye
INTRODUCTION:Absence of inferior vena cava (IVC) is a rare congenital condition, present in less than
0.5% of the population. This congenital abnormality tends to be more prevalent in men. Some
individuals with this anomaly may be asymptomatic and diagnosed during routine imaging for other
conditions. This anomaly may predispose individuals to venous thromboembolism (VTE). We present a
rare case of absent IVC in a young woman who presented with VTE.
CASE PRESENTATION: 28 year old woman with no significant past medical history who presented with
pain and swelling of her left lower extremity. She reported recent travel history of about 4 hours
duration, and she also gave history of oral contraception (OCP) use. She reported left lower extremity
pain was preceded by shortness of breath which was exacerbated by exertion; she however denied
pleuritic chest pain or shortness of breath at rest. Her family history was significant for mother with a
history of two deep vein thrombosis (DVT).
Physical examination was essentially benign except for significant swelling of her left leg and thigh.
Doppler ultrasound of bilateral lower extremities was obtained which was significant for deep venous
thrombosis extending from the left groin to the left popliteal vein. There was no evidence of DVT within
the deep veins of the right lower extremity. Chemistry done was within normal limits; however D-dimer
was elevated at 3762. This prompted evaluation for a pulmonary embolus; ventilation perfusion scan
was completed which was negative. She was anticoagulated and achieved therapeutic INR prior to
discharge.
She presented to the hospital 15 days later with complaints of pleuritic chest pain; it was at this time
CT/PE protocol done was negative for pulmonary embolus but incidental findings showed an elongated
right, middle and posterior mediastinal mass with additional paravertebral soft tissue at the T8 level.
There were soft tissue extensions through multiple bilateral lower thoracic neural foramina into the
spinal canal with mass effect on the spinal cord. This was felt to be consistent with nerve cell tumor
versus other tumor of unclear etiology and MRI was recommended. Patient subsequently obtained
MRI/MRA/MRV chest/abdomen/pelvis which showed dilated azygos vein, hemiazygos vein and lumbar
venous collaterals as well as dilated epidural venous plexus. The inferior vena cava was absent.
DISCUSSION: Anomalies of the IVC are present in 0.3%-0.5% of healthy individuals. These anomalies
include hypoplasia of the IVC, double IVC, left IVC, and the absence of IVC. Congenital absence of IVC has
been reported mostly in men. This is one of the few cases in literature reported in a woman. Absence of
the IVC in any individual is a rare occurrence and usually an incidental finding on imaging. It has been
confirmed as a critical risk factor for deep vein thrombosis in young patients because of resultant
venous stasis. It is therefore recommended that young patients presenting with DVT, in the absence of
major recognized risk factors should be investigated for possible anomaly of the IVC.
223

GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Mahmoud Abdou, MD
A Rare Case Of Atrial Myxoma In A Patient With Hypertrophic Cardiomyopathy
Mahmoud Abdou, MD, Salim Hayek, MD, Byron R. Williams III, MD - Internal Medicine Residency
Program and Division of Cardiology, Emory University, Atlanta, Georgia, USA
INTRODUCTION: Atrial myxomas are the most common primary cardiac tumors. Patients with atrial
myxomas typically present with obstructive, embolic or systemic symptoms. Asymptomatic presentation
of atrial myxoma is very rare. Furthermore, the association of atrial myxoma with hypertrophic
cardiomyopathy (HCM) has only been reported in three cases in the literature.
CASE PRESENTATION: Here we report the case of a 71 year-old female with known HCM who was
referred to cardiology clinic for placement of an automated implantable defibrillator as primary
prevention of sudden cardiac death. An atrial myxoma was discovered incidentally on pre-procedural
evaluation. She was asymptomatic, and her physical exam was only notable for a faint, grade 1/6 earlypeaking
short systolic murmur at the left upper sternal border that did not change with position. Initial
transthoracic echocardiogram showed asymmetric hypertrophy of the basal and mid anteroseptal wall.
A saline contrast bubble study was positive; prompting a follow-up transesophageal echocardiogram
which revealed what was confirmed in cardiac MRI as a 1.2 x 2.2 cm broad-based irregular mass in the
left atrium arising from the interatrial septum near the foramen ovale. The patient underwent surgical
excision of the left atrial mass and partial excision of the left atrial septum. Review of the histopathology
confirmed the diagnosis of atrial myxoma. She continues to do well, with no evidence of recurrence.
DISCUSSION: Cardiac tumors are infrequent clinical entities with prevalence ranging from 0.001% to
0.030%. Approximately three-quarters of primary heart tumors are benign, with atrial myxomas
comprising three-quarters of those, with the majority originating from the left atrium. Patients typically
present most commonly with cardiovascular symptoms secondary to mitral valve obstruction such as
heart failure and pulmonary hypertension. They may also present with neurologic deficits secondary to
embolic phenomena, as well constitutional symptoms such as weight loss and fever. Asymptomatic
presentation is extremely rare. In our case, the patient did not report to any symptoms of heart failure,
fever or weight loss. The significance of the association of atrial myxoma and HCM is unclear. The
number reported in the literature does not exceed a handful of cases. Both HCM and myxomas have
been described in patients with progressive cardiomyopathic lentiginosis or LEOPARD syndrome, a rare
autosomal dominant disease with complex features involving skin, skeletal and cardiovascular systems.
The patient in this case did not have any features typical of lentiginosis. Management of asymptomatic
cardiac myxomas remains an issue of debate, as there are no clear recommendations to suggest
conservative versus surgical measures.
224

GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Kamiran Jafar, MD
Klebsiella pneumonia meningitis in a patient with latent Strongyloides infection.
Kamiran Jafar, MD, Second Author: Scheherezada Urban, MD, Third Author: Moise Carrington, MD,
Fourth Author: Nomi Traub, MD, Department of Internal Medicine, Atlanta Medical Center, Atlanta,
Georgia.
INTRODUCTION: Klebsiella Pneumonia meningitis in adults is rarely reported in North America. We
report a case of an immunocompetent male with Klebsiella Pneumonia meningitis, which occurred as a
result of a latent Strongyloides infestation.
st1\:*{behavior:url(#ieooui) }
CASE PRESENTATION: A 23 year old Mexican housekeeper with no known medical history presented
to the emergency department with headache, fever, nausea, vomiting and photophobia. On
examination, he was alert but uncomfortable with a temperature of 102.8 and nuchal
rigidity. Laboratory studies showed a leukocyte count of 20.6 with 95.5% neutrophils. His head CT scan
was normal. Lumbar puncture yielded clear CSF with a leukocyte count of 2130 (predominantly
polymorphonuclear cells), total protein of 225 mg/dl, glucose of 39 mg/dl, and a gram stain that showed
few white blood cells and no organisms. The patient was started on Ceftriaxone, Vancomycin, Ampicillin
and Dexamethasone intravenously. Blood cultures were negative, but the CSF culture was positive for
Klebsiella pneumonia that was sensitive to Ceftriaxone. Steroids and all other antibiotics were stopped
and Ceftriaxone was continued for a total of 2 weeks. Subsequently, an induced sputum sample and
multiple stool samples were collected and sent for microscopic examination. Strongyloides stercoralis
larvae were present in the stool. However, serologic tests and sputum samples were negative. HIV
testing was also negative. The patient was discharged without complications after 16 days.
DISCUSSION: Infections with Klebsiella pneumonia are usually hospital-acquired and occur primarily in
immunocompromised patients. In adults, bacterial meningitis caused by K. pneumonia is rare, but cases
have been reported, especially in Asia. In a Taiwanese case series, the proportion of K. pneumonia
meningitis rose from 8% between 1981-1986 to 18% between 1987-1995.
Infections with enterobacteriaceae, such as Klebsiella pneumonia, are also associated with
strongyloidiasis. Strongyloides is an intestinal roundworm that can persist and replicate within the host.
Adult female worms live within small bowel epithelium where they deposit eggs. These eggs hatch and
the larvae migrate into the lumen where they are excreted with feces, penetrate perianal skin to reenter
the host ("autoinfection"), or go through the colonic mucosa to invade the
bloodstream. Migrating larvae may transport gram negative bacteria to the bloodstream, resulting in
sepsis, pneumonia, or meningitis.
In this case, the cause of K. pneumonia meningitis is almost certainly due to migrating larvae. In a review
of 38 cases of serious bacterial infections associated with strongyloidiasis, 21 (55%) had meningitis. In
the 20 patients with a positive CSF culture, Klebsiella pneumonia was the second most common cultured
organism.
Conclusion: The goal of this report is to alert the medical community to the connection between gram
negative infections and strongyloidiasis, particularly in patients from endemic areas.
225

GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Robert D Kung, MD
Arteriovenous Fistula Secondary to Renal Cell Carcinoma: An Uncommon Cause of High Output Heart
Failure
Robert Kung, MD, Salim Hayek,MD, Ilie Barb,MD, Viraj Master,MD, Sarfraz Ali,MD, Stephen
Clements,MD
INTRODUCTION: Arteriovenous fistula is a rare complication of renal cell carcinoma (RCC) but a
reversible cause of high-output heart failure.
CASE PRESENTATION: A 58 year-old male with uncontrolled hypertension presented to the emergency
department complaining of worsening dyspnea on exertion, orthopnea and bilateral lower extremity
edema of several months duration. On physical exam he appeared flushed, and exhibited signs of
hypervolemia, specifically jugular venous distention, diffuse bilateral crackles in all lung fields and warm
lower extremities with bilateral pitting edema. Transthoracic echocardiogram (TTE) revealed a severely
dilated left ventricle with severely reduced ejection fraction of 10%. Despite attempts to diurese and
improve cardiac output with furosemide and milrinone, the patient’s renal function deteriorated. A
Swan-Ganz catheter showed a paradoxically high output state with an elevated cardiac output of 15.2L
and a cardiac index of 5.7 L/min/m 2 , raising suspicion for a systemic arteriovenous fistula.
Retroperitoneal ultrasound revealed a soft tissue density, further characterized by an MRI as a giant
mass arising from the right kidney, with a dilated right renal vein consistent with a high flow state.
Inferior vena cava catheterization revealed the venous blood above the renal veins had oxygen
saturation 13% higher than below the renal veins. Right renal angiogram showed a highly vascular mass
with feeder vessels, despite no obvious fistula seen. Radical right nephrectomy was performed and
histopathology showed clear cell RCC. The presence of abnormally thickened arteriolar walls confirmed
high grade flow and pressure consistent with AV shunting. Postoperatively, his renal function normalized
and repeat TTE 7 days post-operatively showed significantly improved ejection fraction of 40% and a
normal cardiac index of 2.6.
DISCUSSION: Acquired AV fistulas are a rare complication of RCC. 30% present with cardiovascular
symptoms, with high output heart failure being the most severe. Less than 30 cases have been described
in the literature. In most instances, the diagnosis is established incidentally during angiography or
surgery. The diagnostic workup of AV fistula in the setting of RCC has not been standardized. Venous
oxygen saturation and renal angiography may be used to quantitate shunt flow. Resection of the
neoplasm is associated with improvement in cardiac function and heart failure symptoms. This case also
highlights how the initial TTE misled us to believe he was in a low cardiac output state; however, the
velocity time integral, an indirect measure of cardiac output, was consistent with a high output state
and attention to this would’ve prevented the delay in diagnosis.
226

GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Scheherezada Urban, MD
Empty Sella Syndrome Masked By Chronic Steroid Exposure Scheherezada Urban MD, Collette Jonkam
MD, Muhammad Shah MD, Hisham Taher MD, Israel Orija MD Department of Internal Medicine at
Atlanta Medical Center, Atlanta, GA
Scheherezada Urban, MD
CASE PRESENTATION: An 80-year-old African American female presented with severe fatigue to the
point she became bedridden, back and knee pain for 2 weeks. She had a longstanding history of
hypothyroidism, generalized DJD and heart failure. She received intra-articular steroid injections every
1-3 months for 2 years with increasing doses over the past several months due to worsening pain. On
presentation she was in severe painful distress, blood pressure was 157/80 mmHg and other vital signs
were stable. Physical exam was remarkable for significant bilateral lower extremity pitting edema.
Further evaluation showed a random cortisol level of 1.0 mcg/dL, TSH was low/normal and free T4 was
low. ACTH stimulation test revealed a cortisol of 2.0, 4.5 and 6.0 mcg/dL at 0, 30 and 60 minutes
respectively, confirming adrenal insufficiency. ACTH was 15.1 pg/mL (10-60) and prolactin 38.2 ng/mL
(normal

HAWAII POSTER FINALIST - CLINICAL VIGNETTE Ekamol Tantisattamo, MD
Anti-N-Methyl D-Aspartate Receptor Encephalitis: Rare Autoimmune Encephalitis as A Commonly
Misdiagnosed Psychiatic Illness
Ekamol Tantisattamo, MD; Melvin H.C. Yee, MD
INTRODUCTION:Confounded by presenting with neuropsychiatric syndromes, anti-N-methyl Daspartate
receptor (NMDAR) encephalitis is often misdiagnosed as psychiatric illness and delays the
recognition. We report a case of man presenting with right leg stiffness, new-onset seizures, and
fluctuating behavioral symptoms. Antiepileptics were started, and he was placed on Behavioral Health
Hospital. Eventually serum anti-NMDAR antibody was found to be positive. The symptoms were
resolved after plasmapheresis, high dose steroids, and rituximab were initiated.
CASE PRESENTATION: A 27 year-old healthy man presented with recurrent episodes of short period of
stiffness and weakness of his right leg. He had ataxia and hyperreflexia on both ankles. Ten days later,
he developed partial seizures with secondary generalization. Lumbar spine MRI showed degenerative
disc disease in L5-S1 levels without spinal compression or disc herniation. Brain and neck MRI/MRA were
unremarkable. Lumbar puncture was performed. Cerebrospinal fluid (CSF) was normal, and VDRL in CSF
was non-reactive. Electroencephalogram revealed no epileptiform activity. Vitamin B12, TSH, ESR, and
ANA were unremarkable. He was started on several anticonvulsants, but he could not tolerate side
effects of the medications; therefore, all anticonvulsants were discontinued. He had a second episode of
seizures, and lacosamide was started. One month later, he started having behavioral change including
agitation, combative, crying, and talkative. He wandered around his house. He had further deterioration
of his cognitive status and episodes varying from catatonia to agitation and self immolation. Quatiapine
was started to control the psychiatric symptoms. Because of worsening psychiatric symptoms, he was
transferred to psychiatric behavioral health hospital. Extensive workups for his neuropsychiatric
symptoms were performed due to unusual new-onset seizures and psychiatric symptoms. Serum anti-
NMDAR IgG antibody was positive. Scrotal ultrasonography, chest CT scan, and whole body PET scan did
not showed evidence of underlying malignancy. He was treated with high dose intravenous
methylprednisolone and plasmapheresis for 5 treatments, and then was placed on maintenance oral
prednisone and rituximab. He gradually returned to his baseline neurological status, and psychiatric
symptoms were resolved.
DISCUSSION: Sudden onset of leg stiffness, new-onset seizures, frontostriatal syndrome, and limbic
symptoms in our young healthy patient is atypical, but may lead to misdiagnosis and treatment with
antiepileptics and antipsychotics which have potential side effects. Anti-NMDAR encephalitis is very rare
para- or nonparaneoplastic-related autoimmune encephalitis presenting with neuropsychiatric
syndromes and seizures. As it is one of the autoimmune encephalitides which can be treated with
dramatic response, a high index of suspicion and workups are warranted.
228

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Vijaya Sivalingam
Ramalingam, MBBS
Chapter Winning Abstract- Not a patient for hand clinic!
Vijaya Sivalingam Ramalingam, MBBS-Associate
INTRODUCTION:Superior pulmonary sulcus tumors (Pancoast tumors) were initially described by H.K.
Pancoast in two publications, in 1924 and 1932. Musculoskeletal and neurological complaints being the
predominant initial manifestation often mislead the clinician, thus delaying diagnosis and appropriate
treatment. We report this case to emphasize the importance of considering Pancoast tumor in high risk
patients with shoulder pain.
CASE PRESENTATION: A 76 year old Caucasian man presented to the Emergency Department with
worsening of right shoulder pain for 2 days. He gave a 6 month history of sharp, persistent, right
shoulder pain, radiating to medial aspect of arm and forearm. It was associated with numbness and
tingling. He was evaluated at the spine and hand clinics and eventually underwent carpal tunnel release
and ulnar nerve reposition surgeries. Upon admission, examination revealed a hard, non mobile mass in
the right supraclavicular fossa. Chest radiograph revealed a soft tissue density in the right lung apex. CT
chest demonstrated a right superior sulcus tumor with extension into the central spinal canal at the
level of T1 and T2. MRI spine revealed a large right upper lobe apical mass involving the supraclavicular
fossa, right posterior cervical space, prevertebral musculature with osseous and epidural invasion from
C7 through T2 and multiple destructive soft tissue masses involving the posterior ribs. A fine needle
aspirate of supraclavicular portion of the lung mass demonstrated neoplastic plasma cells. A bone
marrow biopsy confirmed multiple myeloma and he was diagnosed with an unusual case of Pancoast
syndrome caused by multiple myeloma with extramedullary dissemination to lung. He completed a
course of palliative radiation to the right lung mass and is currently on chemotherapy.
DISCUSSION: Pancoast tumors are primarily non-small cell lung cancers. Multiple myeloma presenting
as Pancoast syndrome is extremely rare. The prognosis of these patients is poor. The typical thoracic
manifestations of multiple myeloma are bony involvement of the thoracic cage or a pulmonary infiltrate
secondary to infection. These tumors, by their close vicinity to neurovascular structures like brachial
plexus and subclavian vessels, often present with musculoskeletal pain and distal neurologic symptoms
resulting in referral to orthopedicians or physiotherapists. Patients are initially treated for arthritis and
bursitis of shoulder and a delay of 6-9 months have been reported in many cases before the tumor was
discovered. Extensive tumors, diagnosed in late stages, have poor prognosis and are considered only for
palliative therapy. We emphasize the importance of considering Pancoast tumor in the differential
diagnosis and performing a thorough evaluation of the chest whenever middle-aged persons present
with persistent shoulder or neck pain. This report will also help clinicians recognize the association
between Pancoast syndrome and multiple myeloma.
229

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jeffrey R Borgeson, MD
Chapter Winning Abstract
Jeffrey Borgeson, Maryam Zia
INTRODUCTION:Thrombocytopenia induced by viral infection is a well-documented phenomenon.
Epstein-barr virus, parvovirus B19, HIV, and hepatitis viruses are all known to cause
thrombocytopenia. CMV infection leading to thrombocytopenia in the organ transplant recipient and
HIV patient is well known; however, CMV infection resulting in thrombocytopenia in the
immunocompetent host is exceedingly rare. Here we present a case of CMV-induced severe
thrombocytopenia in a young immunocompetent adult.
CASE PRESENTATION: The patient was a 22-year old male with a history of Hodgkin's Lymphoma
treated successfully by ABVD 8 years prior who presented to an outside institution with diffuse petechia
and eccymoses after minor trauma. On examination he was found to have both oral mucosa and skin
petechiae, and eccymoses over his right shoulder. He was without fever, lymphadenopathy, or
splenomegaly on exam. His platelet count initially was 1000 per uL. At this point he was treated for a
suspected ITP with steroids, intravenous immunoglobulin, and Rh immune globulin without a platelet
response. HIV antibodies, hepatitis serologies, EBV, parvovirus B19, ANA, anti-platelet antibodies, and
anti-phospholipid studies were all negative. Bone marrow examination showed a normal number of
megakaryocytes with normal morphology, so splenectomy was performed. Despite this, severe
thrombocytopenia persisted. The patient was discharged home but was soon readmitted to our
institution for melena, hematuria, and a platelet count of 16,000 per uL. The patent was treated with
rituximab and romiplostim which resulted in platelet increases to 20,000/dl 1-hour after platelet
transfusions that sustained for about 24 hours before drifting back down to the 5,000-10,000/dl range.
In light of the transient response to platelet transfusions, other causes for the thrombocytopenia were
considered and a CMV pcr was found to be positive at 137,000 copies/mL. All immunosuppressive
therapies were held, and the patient was started on valgancyclovir orally. Within 3 weeks of initiation of
the antiviral therapy, his platelet count increased to 250,000 and his CMV viremia was
suppressed. Three months after intiation of antiviral therapy his CMV viremia remains suppressed and
his platelet count remains in the normal range.
DISCUSSION: Although ITP refractory to corticosteroids at presentation can occur, failure of the initial
line of therapy should prompt further investigation including bone marrow examination. In light of this
patient’s prior treatment with chemotherapy, myelodysplastic syndrome was considered early in the
differential diagnosis. There have been multiple cases reported in the literature of CMV-associated
thromboyctopenia in the immunocompromised host with some cases responding to immunosuppressive
therapy and others responding to antiviral therapy. Given our patient's poor response to
immunosuppressive therapy, it is thought the patient experienced a direct cytopathic effect from CMV
infection as opposed to immune globulin-mediated platelet destruction.
230

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Ayokunle Temidayo
Abegunde, MBBS
Three faces of pylephlebitis: to anticoagulate or not to anticoagulate
Ayokunle Temidayo Abegunde, MBBS, Waldo Herrera, MD, Naser Yamani, MD, Doris Galina, MD
INTRODUCTION: Suppurative thrombosis of the portal vein (pylephlebitis) is a rare condition with an
incidence of 0.01% in hospitalized patients, and a mortality rate of about 11 to 32%. The role of
anticoagulation in the treatment of pylephlebitis is unclear. Available evidence suggests that effective
antimicrobials without anticoagulation can achieve re-canalization of the portal vein. Therefore, routine
anticoagulation is not recommended unless there is evidence of progression despite adequate antibiotic
therapy.
CASE PRESENTATION: Objectives
Describe the clinical presentation and report the outcome of a cluster of three cases of non-cirrhotic
pylephlebitis managed with and without anticoagulation at our institution.
Methods
We report three cases of pylephlebitis with different clinical presentations, seen over an eight-week
period. Only one of the three patients was treated with anticoagulation. The decision to give or not to
give anticoagulation was made by the primary attending physician. After discharge from the hospital,
patients were followed prospectively with abdominal CT scans to evaluate for recanalization of the
portal vein. We also conducted a Medline review of the literature on the evidence of anticoagulation for
pylephlebitis. The key words included were pylephlebitis, septic thrombophlebitis, and portal vein
thrombosis.
Results
Three male patients with a mean age of 52.7 years (58, 53, 47 years) were admitted with acute
cholecystitis, gastroenteritis, and cholangitis, respectively. Blood cultures were positive for
Streptococcus millieri, Proteus mirabilis, and Bacteroides fragilis. Admission abdominal CT scans
revealed acute thrombosis of the portal vein in all three patients. They all received culture directed
antibiotics. In the patient treated with anticoagulation a CT scan of the abdomen performed six months
after initial presentation revealed complete recanalization of the main portal vein with a small residual
thrombus in its right branch. The two patients who did not receive anticoagulation had persistence of
portal vein thrombosis with cavernous transformation in the follow-up CT scan of the abdomen.
DISCUSSION: Our small case series suggests that anticoagulation has a small benefit in achieving recanalization
of the portal vein six months after diagnosing pylephlebitis. This is supported by our
literature review that indicates a slight benefit of anticoagulation, particularly, in patients with
progression of pylephlebitis, and/or hypercoagulable states. However, there is very limited information
regarding the optimal duration of anticoagulation. The available evidence for anticoagulation in the
management of pylephlebitis cannot be generalized to all patients. Therefore, clinical judgment on a
case-by-case basis is advised.
231

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kumar Kunnal Batra, MD
EBV VIREMIA CAUSING COLLAPSING FOCAL SEGMENTAL GLOMERULAR SCLEROSIS
Kumar Kunnal Batra, MD Javier Gomez, MD
INTRODUCTION: FSGS is a glomerulopathy most commonly associated with HIV infection. It is also
associated with other infectious diseases such as parvovirus B19, cytomegalovirus, leishmaniasis,
pulmonary tuberculosis, hepatitis C virus and HTLV-1 [1].
We present a case of disseminated Epstein Barr virus (EBV) infection as a cause of collapsing focal
segmental glomerular sclerosis (FSGS). To our knowledge, this association has never been reported in
the medical literature.
CASE PRESENTATION: A 21 year old female with no past medical history and no history of trauma,
presented with complaints of dull left flank pain, fatigue, and subjective fevers. She was found to have
temperature of 102.9 F, splenomegaly, and tenderness to palpation in left upper quadrant. Labs showed
hemoglobin of 6.5 g/dl, WBC of 15,000 and 13% bands, as well as an LDH of 746 U/L. CT of the abdomen
showed marked splenomegaly with areas of infarction.
During her hospital course she continued to have fevers up to 103, and developed anasarca. Creatinine,
which was normal on admission increased to 1.9 mg/dl, and she started having nephrotic range
proteinuria, her LDH increased to 1273 U/L and she had persistent thrombocytosis. Renal biopsy showed
collapsing FSGS. Further testing to determine the etiology of her collapsing FSGS including HIV Elisa and
viral load, Blood and Urine cultures, Histoplasma serologies, Hepatitis serologies, CMV IgM, autoimmune
panel, JAK-2 mutation, flow cytometry and bcr/abl mutation where all negative. Bone marrow biopsy
did not show any abnormal cell clusters or morphology, favoring reactive thrombocytosis. EBV DNA and
IgG and IgM for EBV viral capsid antigen were positive. Repeat CT showed worsening splenomegaly with
approximately 50% of the spleen being infarcted so she was taken for splenectomy and her spleen
biopsy showed multifocal infarctions with positive in-situ hybridization for EBV.
The diagnosis of disseminated EBV infection with secondary collapsing FSGS was made. Her fevers
improved after splenectomy. She was started on an enalapril for her proteinuria which gradually
improved and her edema resolved.
DISCUSSION: In this case the etiologic diagnosis of the patient’s collapsing FSGS was elusive at first
because the evaluation for all the known causes of this disease was negative. However her clinical
presentation led us to the consider a systemic EBV infection, this was confirmed by positive EBV IgG,
IgM, viral capsid antigen, and EBV DNA [2]
In our literature review, EBV infection as the etiology of collapsing FSGS has never been reported; hence
this would be the first case description of such an association.
EBV infection should be included as one of the possible etiologies of non HIV related collapsing FSGS
In our patient, the clinical course was benign with full recovery of renal function.
232

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Stephen A Boateng, DO
Ventricular Myxoma: A Case Of An Elephant In The Chest
Stephen A Boateng, DO Bruce Wilson, MD Jason Robin, MD
INTRODUCTION: A NSTEMI secondary to coronary occlusion has been encountered by almost every
internist. However, the etiology of this phenomenon may not always be so familiar. This case highlights
the importance of a broad differential when confronted with the routine.
CASE PRESENTATION: A 74 yo white male with a history of hypertension, and hyperlipidemia,
presented to the emergency department with chest tightness and pressure. These symptoms started
the previous day while he was exercising on a treadmill. He denied any other associated symptoms. His
family history was significant for a father and 3 paternal uncles who died of myocardial infarctions in
their fifties. He had never smoked and exercised four times a week.
Physical exam was unremarkable. Cardiac markers were elevated and an EKG revealed a new left bundle
branch block. A cardiac catheterization proved insignificant for occlusive CAD. Echocardiography,
however, revealed a large, mobile left ventricular mass. A Cardiac MRI further characterized the mass
and a small transmural infarct of the basal septum was noted. On pathological exam, the gross findings
of the tumor were consistent with a myxoma. Surgical excision was then performed and after a few days
in the unit, the patient was discharged home without any further complications.
DISCUSSION: Primary cardiac tumors are very rare (0.1 percent incidence). Myxomas account for half
of all cardiac tumors; however, ventricular myxomas are extremely rare as almost all myxomas occur in
the left atrium. The classic triad of clinical symptoms, with which patients present, is congestive heart
failure (67%), signs of embolization (29%), systemic or constitutional symptoms such as fever, or fatigue
(17%). Thus, our patient’s sole presenting symptom of angina was atypical, and may be explained by
intracardiac obstruction to blood flow. In about 5% of patients, these tumors are familial and follow an
x-linked inheritance pattern (The Carney Complex).
A transthoracic echocardiogram (TTE) is useful in the early detection of cardiac masses. A cardiovascular
MRI is, however, preferable for the diagnosis and characterization of cardiac masses. It provides a wide
field of view, generates high contrast and spatial resolution, performs multiplanar imaging, and allows
precise localization and characterization of a mass. Thus, it arms the clinician with precise information in
the absence of a tissue diagnosis.
For most myxomas, surgical intervention is usually curative, and local recurrence is very rare. When left
untreated, however, the complications from such tumors can be grave - congestive heart failure, sudden
death, cardiac arrhythmias, infections, or embolization to vital organs such as the kidney or brain. This
case highlights the importance of maintaining a broad differential in our approach to cardiac ischemia.
While atherosclerosis is the most common cause; it is only one of many causes and the clinician should
always maintain a keen judgement.
233

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kalyani Chandra
PAINFUL THIGH – ARE WE MISSING THE DIAGNOSIS?
Kalyani Chandra Second Author: Kiran Narreddy Faculty Author: James Kumar
INTRODUCTION: Immunosuppression predisposes to a wide variety of infections, some often
underdiagnosed due to lack of suspicion. Awareness about such conditions helps in early diagnosis and
treatment, preventing significant mortality and morbidity. We here report a case of spontaneous
pyomyositis in an undiagnosed Diabetes Mellitus (DM).
CASE PRESENTATION: A 58-year-old Caucasian male with no significant past medical history presented
to the clinic with chief complaint of bilateral thigh pain of four weeks duration. Pain was 10/10 constant,
non-radiating, aggravated by walking, no significant relieving factors, associated with intermittent fever
and chills. He recently had few long drives. No history of trauma, sick contacts, or recent illness. Family
history was positive for DM in father and sister. On examination, a tender cord like structure was
palpated on medial left thigh and tenderness elicited over medial right thigh. No regional
lymphadenopathy. Distal pulses normal. Bilateral lower extremity duplex ruled out deep venous
thrombosis, but showed a non-vascular structure suspicious for hematoma or abscess in both thighs.
Initial labs were remarkable for glucose of 444mg/dl. D-dimer and creatine kinase levels were within
normal limits. Magnetic resonance imaging (MRI) of both thighs showed signal characteristics suggestive
of intramuscular abscess. He was hospitalized and Computed tomography (CT) guided drainage of the
intramuscular abscess was done which grew Staphylococcus aureus sensitive to methicillin. Glycosylated
hemoglobin was 11.4%. Patient responded well to good glycemic control and intravenous antibiotics.
Follow up CT scan of thighs showed decrease in size of the abscesses.
DISCUSSION: Very few cases of pyomyositis as the initial manifestation of DM have been reported.
Pyomyositis, also called pyomyositis tropicans due to its endemicity in tropical regions, is increasing in
incidence in the temperate regions, with immunosuppression being a significant predisposing factor.
Most common site is thigh (54%), followed by back (13%). It is not always trauma related. Creatine
kinase levels are often normal. 75-90% of cases are caused by Staphylococcus aureus with mortality of
up to 10%. CT guided drainage helps in optimizing treatment. Painful thigh in patients with DM,
immunodeficiency, malignancy, cirrhosis, renal insufficiency, organ transplant, intravenous drug abuse
and those on immunosuppressive agents should raise high index of suspicion for pyomyositis. Timely use
of CT or MRI helps in early diagnosis and initiation of treatment thereby preventing significant morbidity
and mortality.
234

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jatin Chhabra, MD
I have tried everything for this headache Doc. It just doesn’t go away!!
Jatin Chhabra, MD Second Author: Puneet Agarwal, MD Third Author: Nilofar Rahman, MD
INTRODUCTION:Headache is a very common complaint amongst patients presenting to the primary
care physician (PCP). Its overall prevalence is estimated to be around 12 to 16% in North America and
Europe. Most headaches are benign and are not associated with a potentially life threatening illness.
However, a detailed history and physical examination are the keys to distinguishing potentially serious
from benign headaches. Here is a case report of a 32 year old female who presented with a rare cause of
headache.
CASE PRESENTATION: A 32 year old female with a past medical history of migraines presented to her
PCP with worsening headaches for the last one week. Her exact words were “this headache just feels a
little different Doc.” She was sent home with Sumatriptan for acute attacks, having already been well
controlled until recently on prophylactic topiramate therapy. A few days later, the patient presented to
the Emergency Department with generalized tonic clonic seizures. A CT Brain without contrast only
showed a soft tissue attenuation in the right maxillary sinus suggestive of sinusitis. Review of
medications revealed that the patient had been on oral contraceptive pills (OCPs). Papilledema was seen
on funduscopy. A subsequent MRI Brain showed mildly increased signal with mild diffuse restriction in
the high left frontoparietal lobe. MRV of the brain confirmed a subtotal thrombosis of the superior
sagittal sinus possibly extending into the left transverse sigmoid sinus and jugular foramen. She was
started on a heparin infusion and antiseizure medication (levetiracetam and topiramate) and was
subsequently discharged after bridging over to warfarin. The hypercoagulable workup sent prior to
initiating anticoagulation came back as unremarkable.
DISCUSSION: Cerebral sinus venous thrombosis (CSVT) is a rare but distinct cerebrovascular disorder
that most often affects young adults and children. The estimated annual incidence is 3 to 4 cases per 1
million population. Headache is the most common symptom, occurring in up to 89-90% of cases and
seizures in 40%. Other signs of intracranial hypertension such as papilledema may also be seen, hence a
fundoscopic examination in a patient presenting with headaches (and red flags such as in this case) is
indispensable. Major risk factors for CSVT include prothrombotic conditions, OCPs, pregnancy,
malignancy, infection and head injury. A head CT may be normal in up to 30% of cases and show indirect
signs in around 40% of cases. However the accuracy is 90-100% when combined with a CT venography
or MR venography. As a result, I think this case rightly highlights the importance of a good history
(identifying red flags) and physical examination including fundoscopy in an outpatient setting!!
235

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jatin Chhabra, MD
Acute Coronary Syndrome due to an unusual variant of Coronary Artery Disease!!
Jatin Chhabra, MD Second Author: Puneet Agarwal, MD Fourth Author: Nilofar Rahman, MD
INTRODUCTION:Acute coronary syndrome (ACS) refers to a spectrum of diseases ranging from
unstable angina (UA), to non–ST-elevation myocardial infarction (NSTEMI), to ST-elevation myocardial
infarction (STEMI). In the majority of cases, it is due to atherosclerosis of the coronary arteries or
coronary artery disease (CAD). CAD is a major cause of death and disability in developed countries,
accounting for about one third of all deaths over the age of 35. Here is a case of a young 49 year old
man who presented with NSTEMI due to a relatively rare variant of CAD.
CASE PRESENTATION: A 49 year old African American male with a past medical history of hypertension
and HIV infection presented to the Emergency Department with classic substernal squeezing chest pain
radiating to the left arm. The EKG showed non specific ST-T segment changes and Troponin I went up to
0.17 ng/ml. Despite an Aspirin, two sublingual nitroglycerines and nitropaste, the patient’s pain
persisted, though less in intensity. CT Chest with contrast was negative for pulmonary embolism. He was
started on a heparin infusion and a subsequent coronary angiography revealed nonobstructive coronary
atherosclerosis, ectatic coronary arteries and a 1.5-2cm aneurysm of the mid segment of the left
anterior descending artery. No thrombus was noted in the aneurysm and the left ventricular systolic
function was normal (EF 55%). His pain gradually abated while on the heparin infusion and he was
subsequently discharged home on warfarin.
DISCUSSION: Coronary artery aneurysm (CAA) is defined as a localized dilatation exceeding the
diameter of the adjacent normal coronary segment by more than 50%. The prevalence ranges from 1.5
to 5% in patients with CAD. Over 50% of the aneurysms are atherosclerotic in origin and are considered
a variant of CAD, but the exact mechanism leading to the development of ectasia in these vessels is
unknown. It is most common in the right coronary artery and least in the left main coronary. The second
most common cause is Kawasaki disease followed by congenital etiology, autoimmune disease, trauma,
dissection, infection and angioplasty. The main complications include thrombosis, distal embolization,
rupture and vasospasm. Coronary angiography is the gold standard but transesophageal
echocardiogram is a good tool and can be used to follow changes in size, especially for proximal
segments. In the absence of obstructive CAD, definitive treatment is unclear but usually includes only
medical therapy (antiplatelet therapy and anticoagulation) as in this case. With coexisting significant
flow limiting disease or a giant aneurysm (>2cm), surgical therapy or percutaneous stent placement is
essential. Our patient may have had thrombus formation, rapid dissolution of the clot and distal
microembolization.
236

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Swapna Devanna, MBBS
An Unusual Case of Abdominal pain
Swapna Devanna, Co Authors: Adam King, Dheeraj Reddy, Mudita Bhugra, Aman Ali
CASE PRESENTATION: A 41-year-old male presented with third episode of Right Upper Quadrant
(RUQ) and epigastric pain in last four months. Abdominal pain radiated to his back and was aggravated
by eating. He also has tea colored urine and pale stool. On a physical exam, he had positive Murphy’s
sign, diffuse abdominal pain and mild icterus. His laboratory data showed elevated liver enzymes,
amylase, lipase and direct bilirubin. His CT scan of Abdomen was consistent with pancreatitis and RUQ
ultra sonogram was negative for choledocholithiasis. He had ERCP/EUS with stent placement in
Common Bile Duct (CBD) without evidence of pancreatic mass or stones. He had negative work up for
other causes of pancreatitis except for elevated IgG4 and CA 19-9. Biopsy specimens were negative for
malignancy. Specimen sent to the mayo clinic showed numerous IgG with only rare IgG4 positive plasma
cells. Diagnosis of Autoimmune pancreatitis is considered. After initiation of steroid treatment patient
had significant improvement in his symptoms and appearance of CBD and pancreas on repeat
ERCP/EUS. His liver and pancreatic enzymes also normalized.
DISCUSSION: Autoimmune pancreatitis (AIP) has prevalence of 0.7 per 100,000. 85% of patients are
males who are more than 55 years of age. It may be associated with other autoimmune diseases.
Obstructive symptoms are most common presenting symptom. 47% of these patients have elevated
CA19-9, which normalizes after steroid treatment in almost all patients. On Histology, they have
lymphocytic infiltration with plasma cells, which typically expresses IgG4. Sausage shaped appearance of
the pancreas and long non-beaded appearance of CBD and intrahepatic bile ducts are common features
seen on CT scan.
Autoimmune pancreatitis (AIP) can be particularly challenging to diagnose because it closely resembles
pancreatic cancer. There is no single test or characteristic feature that can be used to identify AIP. Mayo
Clinic HISTORt diagnostic guidelines for AIP is helpful, so that the disorder can be correctly identified and
unnecessary surgery be avoided. The HISTORt criteria include Histology, Imaging, Serology, other organ
involvement and response to steroid therapy. Imaging of the pancreas is the first step in diagnosing AIP.
A common feature of AIP is elevated serum IgG4. Because AIP is the only pancreatic disorder known to
respond to corticosteroids, trial course of this drug is used to confirm a diagnosis. If symptoms improve,
for instance, IgG4 level drops or a mass in pancreas shrinks patients are considered to have AIP. Before
starting corticosteroids treatment, it is imperative to exclude malignant process in pancreas that mimics
the presentation of AIP.
237

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Deepa Dharanipragada,
MBBS
A 48-year-old Chinese Man With Unremitting Fever
Deepa Dharanipragada, MBBS Second Authors: Seshan Subramanian, MD, Third Author: Carlos F Garcia,
MD
INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is challenging diagnosis to make given its
rarity and dynamic presentation patterns. We discuss a case of Epstein-Barr virus (EBV)-associated HLH
which masqueraded as sepsis.
CASE PRESENTATION: A 48-year-old Chinese man with no known medical problems presented with
fever, weight loss, and upper respiratory tract infection for one month. On examination, he was
tachycardic, tachypneic, hypotensive and febrile with 39.4 centigrade. There was no rash,
lymphadenopathy or appreciable organomegaly. The rest of the examination was unremarkable. The
chest x-ray showed no acute cardiopulmonary process. He was hemodynamically stabilized with
intravenous fluids, pancultured and started on empiric antimicrobials. Despite this, unremitting fever
continued. Detailed investigative work-up was significant for pancytopenia, normal fibrinogen level,
hyponatremia, hypoalbuminemia, transaminitis, mild elevation of triglycerides and a negative
monospot. Pan-computed tomography showed maxillary sinusitis and splenomegaly. Bone marrow
biopsy revealed focal areas of hemophagocytosis. HLH was suspected. Ferritin level was ordered and
was found to be 11,862 ng/ml confirming the diagnosis of HLH. Extensive work-up to determine etiology
continued, as management of HLH differs based on the underlying cause. Infectious and autoimmune
work-up was negative except for viral serologies consistent with previous exposure to EBV. At this
point, he was started on steroids, resulting in symptomatic improvement. Antimicrobials were
discontinued. He was discharged home afebrile with outpatient follow-up. Four days later, he was
readmitted with fever and fatigue despite his compliance with prednisone. Oral cavity showed exudates.
Pancytopenia and transaminitis worsened. Vancomycin and acyclovir were addded to prednisone
empirically. Repeat panculture and monospot test were negative. Repeat bone marrow biopsy showed
focal areas of hemophagocytosis with no signs of malignancy. Given the positive EBV serology, Epstein-
Barr viral load was ordered. A trial of intravenous immunoglobulin led to hypotension with further
worsening of fever and pancytopenia. Empiric management for neutropenic fever was started. The
following day, Epstein-Barr viral load results became available and showed 1,018,245 copies/ml leading
to a diagnosis of EBV-associated HLH. The patient was started on etoposide with subsequent significant
improvement in symptoms.
DISCUSSION: HLH encompasses immune dysregulation and cytokine storm. It can develop subsequent
to genetic mutations or in association with infection, malignancy or autoimmune conditions. Timely
diagnosis and identification of the underlying cause is critical to effectively manage this potentially lethal
condition. Five of the following eight criteria are needed for the diagnosis of HLH: fever, bicytopenia,
splenomegaly, hypertriglyceridemia and/or hypofibrinogemia, hemophagocytosis, low or absent NK-cell
activity, hyperferritinemia, increase in soluble CD25 levels. Management of EBV-associated HLH should
be geared at reducing the uncontrolled immune response and elimination of EBV infection. Studies
showed survival benefit with early administration of etoposide in EBV-associated HLH.
238

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kinza Gul M.D;
Catecholaminergic Polymorphic Ventricular Tachycardia: A Stress induced Phenomenon.
Kinza Gul M.D Saad Muhammad M.D, Prakash Thopiah M.D
INTRODUCTION:Although catecholaminergic polymorphic ventricular tachycardia (CPVT) is rarely
encountered, physicians should be aware of this fatal arrhythmia. It can present in susceptible
individuals most likely during a stress test. A careful personal and family history is important to suspect
this disorder although sporadic cases can also manifest for the first time. Once diagnosed, it is important
to initiate adequate treatment and proper counseling.
CASE PRESENTATION: A 44 year old man, with no significant past medical history, was admitted to the
hospital for further evaluation of intermittent chest pain. He had no similar episodes in the past. He
denied symptoms of dizziness, syncope or shortness of breath. His father had premature coronary artery
disease. Otherwise, no history of arrhythmia or sudden cardiac death was reported in family. Physical
exam, including vitals, was normal. Serial cardiac biomarkers and EKG were also normal. He underwent
an exercise stress echocardiogram during which he felt lightheaded. His heart rate escalated from 160
beats per minute to 255 beats per minute. Corresponding EKG recording revealed a polymorphic
ventricular tachycardia. The test was stopped and prompt return to normal sinus rhythm was noted on
cessation of exercise. A trans-thoracic echocardiogram did not show any abnormality. His serum
chemistry, including a magnesium level, was normal. Patient later underwent coronary artery
catheterization, which was also unremarkable. He was started on oral beta-blocker therapy and
remained asymptomatic until he was discharged home. A close follow up with cardiology clinic was
scheduled for evaluation for implantable cardioverter-defibrillator (ICD) placement.
DISCUSSION: Exercise stress test is commonly performed in the hospital. Very rarely, we may
encounter young patients experiencing a fatal arrhythmia during testing. Catecholaminergic
polymorphic ventricular tachycardia is one such arrhythmia. It is a familial disorder, with mutation
identified in two genes (RyR2 and CASQ2). Sporadic cases without family history may also be
encountered. The estimated prevalence of CPVT is 1:10,000. It can be precipitated due to emotional or
physical stress. Symptoms at presentation may vary from syncope or dizziness to sudden cardiac death.
Affected individuals have a structurally normal heart and a normal baseline electrocardiogram.
Diagnosis is clinical, based on positive family history and response to exercise or catecholamine infusion.
Management involves avoidance of competitive sports, initiation of beta blocker therapy and most
patients may ultimately require an ICD placement to avoid sudden cardiac death.
239

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Samrina Hassan, MBBS
Is this a risk-free approach to overcome obesity?
Samrina Hassan, MBBS, MD Second Author: Puneet Agarwal, MBBS, MD Third Author: Jatin Chhabra,
MBBS, MD Fourth Author: Andy Arwari, MD
INTRODUCTION: Obesity is one of the major risk factors for cardiovascular disease, certain types of
cancer, and type-2 diabetes. Healthy eating and regular physical activity is the recommended approach
to weight reduction. We present a different approach to weight reduction, undertaken by one of our
patients and the consequences she encountered.
CASE PRESENTATION: Our patient is a 36 year-old woman (BMI 39) with a history of migraine with
visual aura, who presented to the emergency department with complaints of a headache, associated
with retro-orbital pain and photophobia, weakness in left upper extremity, and slurred speech. She
denied dizziness, nausea, vomiting or balance problems. After an unremarkable CT of the brain without
contrast, CT of the brain with perfusion revealed occlusion of the right middle cerebral artery at the M1
segment. She did not receive tissue plasminogen activator given her delayed presentation. MRA of the
brain and neck was unremarkable but MRI of the brain was most consistent with an area of acute right
basal ganglia infarction. Trans-esophageal echocardiogram was normal. Laboratory evaluation was
negative for a hypercoagulable state. ANA was positive at 1:160, but the lupus panel was entirely
negative otherwise. On detailed questioning, it was noted that for the last six months, she was on oral
contraceptive pills and had been taking over the counter weight reduction supplements, which
contained synephrine as one of the active ingredients. Both these medications were held since
admission in view of a probable role in causing the stroke. She was started on aspirin and a statin and
discharged home after improvement in symptoms. On follow-up, she was noted to have some residual
weakness in the left upper extremity.
DISCUSSION: Our case illustrates the association of weight-reduction products with acute stroke,
especially the ones marketed as ephedra-free compounds. After the ban on ephedra-containing
products, it has led to the emergence of new formulations which are ‘ephedra-free’ but contain other
sympathomimetic agents such as synephrine, the safety of which is not yet established. Synephrine is
similar to ephedra in chemical composition and mechanism of action, but its cardiovascular effects have
not been extensively studied. Young obese adults like our patient are more inclined to use these
products. The critical intervention would be to regulate marketing of such products and implement
restrictions on their ‘over the counter’ sale to prevent further use and its complications, until extensively
studied. At the same time, the importance of a detailed medication history including ‘over the counter’
medications cannot be further emphasized.
240

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Prantesh Jain, MD
Neurosyphilis Treatment Failure or Serofast Syphilis: To Treat or Not To Treat.
Prantesh Jain, MD Shweta Gupta MD
INTRODUCTION:Neurosyphilis can present with personality changes alone, a manifestation often
misdiagnosed as psychiatric problem. Another not so well-known issue is the concept of 'serofast'
syphilis. This case highlights these issues and uncertainties associated with them.
CASE PRESENTATION: A 58-years old lady with past-history of hypertension presented with
progressively worsening personality changes for two-years, including difficulty remembering things,
answers to questions being out of context with progressive unsteady gait requiring some support while
turning. She became socially withdrawn and lost her job. She was sexually inactive for 30-years with no
history of sexually transmitted diseases. Physical examination showed normal vital signs. Systemic exam
was unremarkable except neurological exam which was remarkable for mini-mental exam 26/30 with
difficulty in immediate recall, deep-tendon reflexes 3+ bilaterally and extensor-planter response. Gait
was unsteady with difficulty in tandem-walking. She had normal serum chemistry, blood counts, thyroidfunction
tests and vitamin-B12 levels. HIV serology was negative.
MRI-brain revealed multiple areas of increased signal intensity bilaterally in cerebral white matter at the
subcortical, peri-ventricular region. Serum RPR was positive, titer 1:128. CSF analysis showed normal
glucose, elevated proteins 129mg/dL and WBC count 6/µL with 90% lymphocytes. CSF-VDRL was
positive. She was treated with penicillin-G IV for 14 days and given a cane to support walking. Over next
8 months her personality changes improved near-baseline and she was able to walk without support.
She started a job. However her serum-RPR remained positive, titer 1:64 and repeat CSF showed elevated
proteins with positive CSF-VDRL. She was re-treated for neurosyphilis with 2 weeks of IV penicillin.
Another ten months later, patient was asymptomatic, but RPR remained positive, titer 1:64 with positive
CSF-VDRL. She received a third course of penicillin, this time with probenecid. Then, it was concluded
that the patient may have serofast syphilis and was observed. Her RPR titer 30-months after initial
diagnosis declined two-fold only to 1:32 and post 42-months of diagnosis was 1:16. She continued to do
well clinically.
DISCUSSION: Neurosyphilis can present with variety of clinical and psychiatric symptoms alone or in
combination, both of which the clinician needs to be aware of to make a correct diagnosis. An important
issue is definition of 'serofast' syphilis. Traditionally defined in primary syphilis as persistently elevated
serum-VDRL titers after adequate treatment and resolution of symptoms, its definition in tertiary
syphilis remains unclear. The CSF protein and pleocytosis remain a better indicator of persistent disease
than CSF-VDRL, which may take a very long time to become negative. However, the question of retreatment
becomes important in a patient who becomes asymptomatic but continues to have increased
CSF proteins. A negative CSF-FTA (fluorescent treponemal antibody) test can help identify active disease
but is not recommended by CDC for diagnosing persistent disease and not widely available, making the
diagnosis of persistent neurosyphilis a challenge. Hence, the question of re-treating the numbers or
symptoms in neurosyphilis still remains debatable.
241

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Adrienne N Kovalsky, DO
Ascariasis Presenting As A Polyarthropathy That Resolved After Eradication
Kovalsky A, Schrantz S University of Chicago - Northshore (both authors)
INTRODUCTION:Enteropathic arthropathies comprise a spectrum of disorders, among them reactive
arthritides and spondyloarthropathies. Reactive arthritis is usually associated with bacterial pathogens,
but cases due to parasites have also been reported. Literature on arthropathies attributable to parasitic
infection is limited to two reviews and a handful of case reports. Since 1951, only three case reports
cited Ascaris lumbricoides as the causative pathogen. We report a fourth case of polyarthropathy that
resolved after eradication of Ascariasis.
CASE PRESENTATION: A 27-year-old female with no significant history presented for swollen knees
and ankles. She reported two weeks of swelling ankles, followed by swollen knees and eventually also
wrists. Her pain was minimal but was exacerbated when she was seated for long periods. She had been
living in Ukraine the past year. Two weeks prior to onset she traveled to the Karpathian mountains, a
week prior to onset she noted one day of fever of 38.9 o C associated with forceful vomiting, and four
days later she had a few days of diarrhea. Other history included occasional alcohol consumption and
freelance employment as a translator and editor. Family history and review of systems were
negative. On exam she was fair-skinned and healthy-appearing, and had bilateral two-plus non-pitting
ankle edema and bilateral knee effusions; exam was otherwise unremarkable. Laboratory studies
obtained in Ukraine included normal hematologic studies but differential significant for 27% eosinophils,
normal chemistries, normal liver studies, and negative CRP, RF, ANA, and ASO. Abdominal ultrasound
was also normal. We ordered stool studies for ova and parasites, which were positive for Ascaris
lumbricoides. She was treated with a single course of albendazole. Stool studies were repeated and
positive at two weeks, and negative at four and eight weeks. Her joint edema and discomfort improved
slowly, at six weeks had resolved completely, and at twelve weeks had not recurred.
DISCUSSION: Reactive arthritis occasionally has been associated with helminth infection, and rarely
with Ascariasis. Fever can increase activity of the parasite, and we suspect that our patient's febrile
diarrheal illness was an unrelated infection that increased the activity of the ascarids, resulting in
circulation of higher titers of arthrogenic antigens and triggering her arthropathy. This resolved
completely upon eradication of the ascarids. This case describes an arthropathy in a healthy young
woman with no rheumatologic conditions that resolved after eradication of concurrent
Ascariasis. While Ascaris lumbricoidies is usually associated with tropical climates, it can also be found in
temperate regions of Europe and the United States. It is conceivable that parasitic arthropathies are
underreported and a thorough history including travel, as well as stool studies, should be considered in
any patient presenting with an arthropathy and an otherwise negative workup.
242

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Geeta Kutty, MD
A Case of Corynebacterium Jeikeium Osteomyelitis
Geeta Kutty, MD Bhanushali Keerti
INTRODUCTION:Corynebacterium jeikeium is recognized as an important nosocomial pathogen among
immunosuppressed patients and causes extremely severe clinical manifestations, which may be fatal if
left untreated. A unique case of vertebral osteomyelitis, where Corynebacterium jeikeium was isolated
as the causative bacterium in an immunocompetent patient with no risk factors, is presented below.
CASE PRESENTATION: A 37 year old man with no significant past medical history presented with
bilateral lower extremity weakness and numbness for 3 month. Pertinent physical findings included
normal vitals, clinical signs of upper motor neuron involvement and intact cranial nerves. Laboratory
data revealed normal CBC and metabolic panel. MRI showed para - vertebral soft tissue densities at T9-
12 bilaterally extending into the neural foramen, bony destructive changes with adjacent sclerosis with
the appearance of a chronic infectious process. PPD, HIV, brucella serology, urine histoplasma antigen
and blood cultures were negative. CT guided biopsy of the vertebral lesion performed was inconclusive,
with final pathology showing chronic inflammatory changes but negative for malignancy, tuberculosis,
bacterial and fungal infection. T9-T10 laminectomy with epidural space exploration was done, tissue
pathology revealed chronic osteomyelitis. Gram stain of the tissue showed gram positive bacilli. Patient
was initially started on intravenous ampicillin for presumed Actinomycoses. Tissue culture grew
Corynebacterium Jeikeium and the patient was treated with intravenous vancomycin for 8 weeks. The
patient responded well and was ambulating with a cane on subsequent follow-up at 2 months.
DISCUSSION: Discussion C. jeikeium is a gram-positive rod that exists as part of the normal skin flora,
particularly in the axillary, rectal, and inguinal regions of hospitalized patients. Risk factors for C.
jeikeium infection include hematologic malignancy, neutropenia, intravasular catheter, prosthesis
prolonged hospitalization and exposure to multiple antibiotics,. Few cases of serious C.jeikeium infection
in patients with no risk factors have been reported. The predominant syndrome associated with C.
jeikeium is sepsis, which can occur in conjunction with pneumonia, endocarditis, meningitis,
osteomyelitis or epidural abscess. Of particular concern is the fact that C. jeikeium is resistant to most
antibiotics tested except for vancomycin and teicoplanin. Effective therapy involves removal of the
source of infection and long term antibiotic. Conclusion This case emphasizes the importance of this
group of antibiotic resistant corynebacteria typically known to infect only immunosuppressed patients
as a potential cause of serious infection in immunocompetent patients without any associated risk
factors.
Reference William Riebel, Nancy Frantz, David Adelstein, and Philip J. Spagnuolo Corynebacterium JK: A
Cause of Nosocomial Device-Related Infection: Clin Infect Dis. (1986) 8 (1): 42-49. Boc, S. F., and J. D.
Martone. 1995. Osteomyelitis caused by Corynebacterium jeikeium. J. Am. Podiatr. Med. Assoc. 85:338-
339. Munian MA, Martínez-Martínez L, Suarez AI, Corral JL. Corynebacterium jeikeium osteomyelitis
successfully treated with teicoplanin. J Infect. 1997 Nov;35(3):325-6.
243

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kiran Narreddy, MD
Hematological Abnormalities After Bariatric Surgery: More Than Just Iron And Vitamin B12 Deficiency
Kiran Narreddy, MD; Co-Authors: Krishnarao Tangella MD, Sohail Chaudhry MD
INTRODUCTION: Copper (Cu) deficiency is an under diagnosed cause of various hematological
abnormalities. It manifests as bicytopenia or pancytopenia. Cu is essential for function of numerous
enzymes in the body, including ceruloplasmin, cytochrome c oxidase and copper-zinc superoxide
dismutase. Patients with history of bariatric surgery, gastrectomy, small bowel resection, celiac disease
and prolonged total parenteral nutrition are at risk for Cu deficiency. Review of the literature showed
only few case series to date. We here report the case of 50-year-old female with pancytopenia and
extensive work up finally revealed copper deficiency.
CASE PRESENTATION: A 50-Year-old female presented to the hematology clinic for evaluation of
pancytopenia. Past medical history significant for bariatric surgery performed one year ago. Complete
blood counts were normal prior to surgery. Examination was negative for lympadenopathy and
organomegaly. Initial labs showed pancytopenia, normal Vitamin b12, folic acid and Iron studies. Bone
marrow biopsy showed hypo cellular marrow (10% cellularity) with no obvious myelodysplasia or
malignancy, adequate iron stores, normal cytogenetics and flow cytometric analysis. Patient was
referred to tertiary care center for further evaluation. Further investigations revealed marked decrease
in serum copper and ceruloplasmin levels. Patient was started on intravenous copper chloride infusions
once a month, which led to remarkable improvement in complete blood counts.
DISCUSSION: The physiology of Cu absorption is poorly understood in humans. Copper absorption is
assumed to take place in stomach and proximal small intestine. Copper deficiency also known as
hypocupremia is potentially serious and preventable complication following bariatric surgery. It should
be considered in the differential diagnosis of high-risk patients who presents with unexplained
cytopenias. With increase in number of bariatric surgeries since last decade, our case report aims to
increase awareness among primary care physicians about the hematological manifestations of copper
deficiency. We also emphasize to consider checking serum copper and ceruloplasmin levels during the
initial work up for pancytopenia in high-risk patients.
244

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Ahmet Afsin Oktay, MD
Streptococcus bovis Bacteremia Associated with Composite Lymphoma
Ahmet Afsin Oktay, MD (ACP Associate); Fritzie Albarillo (ACP Associate), MD; Janis Atkinson, MD
INTRODUCTION: Streptococcus bovis (S. bovis) infections in humans are usually associated with
bacteremia and infective endocarditis (IE). Gastrointestinal tract is the main portal of entry for S. bovis.
It has been well known that S. bovis bacteremia, with or without IE, is associated with underlying
malignancy of the colon as well as extra-colonic malignancy or liver disease. Every patient with S. bovis
bacteremia should undergo evaluation for IE and gastrointestinal malignancy.
CASE PRESENTATION: An 86-year-old male patient with past medical history of mild dementia, deep
vein thrombosis, hypertension, and type-2 diabetes mellitus was admitted for generalized weakness and
asymptomatic hypoglycemia. Family members reported that the patient had been having generalized
weakness, poor appetite and had fallen multiple times recently without loss of consciousness. His
medications had included warfarin, metformin and glyburide. When he presented to the ED his vital
signs were within normal limits. On examination he was found to be lethargic, diaphoretic and oriented
only to person and place. Initial laboratory tests were unremarkable except for serum glucose of 69
mg/dL. Initial urinalysis showed hematuria without any sign of urinary tract infection. Blood cultures and
urine culture from the day of admission were negative. On the third day of admission he was found to
have severe sepsis. His blood cultures on that day reported S. bovis and Enterococcus faecalis. The
latter also grew in the urine culture. The patient responded well to intravenous Vancomycin and fluid
replacement. An extensive work-up was done to identify the source of S. bovis bacteremia. Transesophageal
echocardiography showed no evidence of thrombus or vegetation. His colonoscopy showed
a single sessile polyp with no evidence of malignancy. CT of the chest, abdomen and pelvis showed a 4.2
x 5.6 cm intra-abdominal mass adjacent to the liver and diffuse thoracic, abdominal and pelvic
lymphadenopathy. An incisional biopsy of deep cervical/scalene lymph node and immunophenotypic
analysis revealed composite lymphoma: classical Hodgkin’s lymphoma and CD5 positive B-cell
lymphoproliferative disorder.
DISCUSSION: S. bovis bacteremia with underlying lymphoma, mostly gastric lymphoma, was reported
in very few case reports. To our knowledge this is the first S. bovis bacteremia case reported to be
associated with composite lymphoma which is a rare disease and defined by the presence of two or
more distinct lymphoma types in a single lymph note. The underlying mechanism for the association
between S. bovis infection and malignancy remains elusive. We believe that, in our case, the liver
involvement has provided a portal of entry from the hepatobiliary tree for S. bovis. This case supports
the fact that S. bovis bacteremia cases need extensive workup to rule out underlying malignancy.
245

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Tarpan R Patel, MD
To Bleed Or Not To Be: heyde’s Syndrome, A Clinically Under-recognized association Revealed
Tarpan R Patel, MD Second Author: Siegfried Yu, MD
INTRODUCTION: Acute upper gastrointestinal bleeding (GIB) has an incidence of 40-120 episodes per
100,000 persons annually and acute lower GIB has an incidence of 20-27 episodes per 100,000 persons
annually. 1 There is a significantly increased prevalence of aortic stenosis (AS) in patients with
angiodysplasia, a common cause of GIB in the elderly. 2,3 We describe a case of Heyde’s Syndrome (HS), a
clinically under-recognized association, composed of a triad of AS, GI bleeding from angiodysplasia, and
acquired coagulopathy. 4
CASE PRESENTATION: A 65 year old male with known Marfan’s Syndrome and aortic valve
replacement (AVR) x 3 presented to the emergency department with progressive weakness, shortness of
breath, and melena. He had been admitted 10 times in the previous 12 months for GIB. His initial
hemoglobin was 4.5 g/dL, and after stabilization with fluid resuscitation and blood transfusion, he
underwent an urgent upper endoscopy. This revealed brisk, active bleeding from multiple 1-2 mm
arteriovenous malformations (AVM’s) present in the gastric body. The AVM’s were treated with clipping
and injection sclerotherapy.
Due to his AVR history, and the presence of a grade 3/6 systolic murmur that did not resolve with
correction of his anemia, a diagnosis of HS was considered. An echocardiogram revealed severe
bioprostheic valve AS with leaflet calcification and a left ventricular ejection fraction of 28%, confirming
the clinical triad needed to make a diagnosis of HS. Desmopressin, conjugated estrogens, and octreotide
were added to his management. Due to his persistent problems with frequent, severe GI bleeding,
mesenteric angiography was pursued and demonstrated bleeding from the right gastroepiploic artery,
correlating with the lesions found on endoscopy, and embolization was performed. His hemoglobin
stabilized to 9.1 g/dL, and he was discharged home. At his 2 week follow-up, the patient was
asymptomatic with normal stools and a hemoglobin of 10 g/dL AVR was discussed with the patient as a
potential surgical cure, but due to patient’s preferences, non-surgical management was pursued.
DISCUSSION: The association of AS and GIB was first described by Heyde in 1958. 5 Although HS as a
true clinical entity has been questioned, 4 more recent studies confirm a direct association between the
severity of the valvular disease and coagulopathy. 6 High molecular weight multimers of von Willebrand
Factor undergo shear stress-mediated proteolysis due to AS, and this produces an acquired type 2A Von
Willebrand syndrome, which has been demonstrated to improve after AVR in HS. 4,6 This may support
why AS carries an approximate 100-fold increased prevalence of GIB, 3,4 and the observation that the
majority of patients with HS who undergo AVR stop bleeding. 4 Because the ideal treatment for HS is the
replacement of the AV, 4,7 early recognition of HS by health care providers may lead to more effective
treatment, and potential cure. 2-4,6
246

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Nilofar Rahman, MBBS
Looking beyond!
Nilofar Rahman, MD Second Author: Jatin Chhabra, MD Third Author: Vijay Ramalingam, MD Fourth
Author: Crystal Radnitzer, MD
INTRODUCTION: Back pain is the second most common symptom related reason for clinician
visit. Multiple surveys have estimated the prevalence of back pain in different populations. In 2002, US
National Health interview Survey showed that 26% of people experienced back pain lasting a whole day
for 3 months. In about 85% of cases the physiologic cause cannot be estimated. Total cost of low back
pain in the US exceeds $100 billion per year. Here is a case report of a 49 year old M with an uncommon
etiology of low back pain.
CASE PRESENTATION: A 49 year old Caucasian man was admitted for worsening chronic back pain
since 2 months. An outpatient evaluation in the Spine Institute which included MRI of the lumbar and
thoracic spine was unremarkable. He was treated with intraarticular steroid injection and opioid
medication without much improvement. Upon admission his hemoglobin was found to be 7.5 g/dl. An
upper endoscopy revealed a large hemorrhagic gastric polyp which was removed. He was transfused
packed red blood cells and discharged home. However, he had recurrent hospitalizations every month
due to persistent back pain and anemia; also, his repeat EGDs were normal. During his fourth
hospitalization (within a 5 month period), a CT chest/abdomen and pelvis revealed splenomegaly as well
as multiple lytic lesions in the right ilium and sacrum. A CT guided biopsy of the right ilium
demonstrated renal cancer, clear cell type (Furhman grade 4); however a CT abdomen/pelvis and
ultrasound of the abdomen did not reveal any renal mass. The patient underwent palliative radiation to
the spine, however he eventually succumbed to the disease within two weeks following discharge.
DISCUSSION: The incidence of renal cell cancer (RCC) has increased by 3.5% in the past
decade. Approximately 10% of RCC cases present with the classic triad of hematuria, abdominal mass
and pain. Several patients present with symptoms of anemia, hepatic dysfunction and
metastasis. About 5% of RCC metastasize to the bone and less than 3% of them are smaller than 3 cm in
size. Clinicians should have a high level of suspicion in patients presenting with non specific symptoms
of anemia, weight loss etc. Labaratory testing may be significant in suggesting the presence of
disseminated disease, such as: anemia, elevated liver function tests, alkaline phosphatase, or increased
calcium. Multiphasic CAT scan is 100% sensitive for detection of a mass greater than 15 mm in size. An
early diagnosis may improve morbidity by preventing further complications like Budd-Chiari syndrome,
pulmonary emboli and paraneoplastic manifestations.
247

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Nilofar Rahman, MBBS
Heart and Brain – An Unknown Connection
Nilofar Rahman, MD Second author: Puneet Aggarwal, MD Third Author: Jatin Chhabra, MD Fourth
author: Christopher K. Bodine, MD
INTRODUCTION:Nearly 14 million Americans have symptomatic coronary artery disease (CAD) and
results in one death every minute. Given this enormous disease burden both patients and physicians
worry of potential symptomatic CAD as a cause for chest pain. In such a diagnostic environment there is
an increasing need to be aware of non CAD related causes of cardiac chest pain
CASE PRESENTATION: : A 77-year-old woman presented to the hospital with mid sternal chest
tightness after an altercation with a family member. Symptoms lasted 30 minutes and were
accompanied by shortness of breath, diaphoresis and nausea. She had similar episodes of chest
tightness while climbing stairs or under emotional stress. Physical examination was unremarkable. Her
electrocardiogram (EKG) did not reveal changes consistent with cardiac ischemia and was unchanged
from prior EKG. Laboratory evaluation revealed clinically significant elevation in troponin at 1.62 ng/ml
(normal - 0.00-0.04ng/ml). Transthoracic Echocardiogram (TTE) was performed which showed akinesis
of the apical and infero-apical segments of the myocardium. There was associated moderately
diminished left ventricular systolic function with an ejection fraction of 35%. Cardiac catheterization
was performed which showed no evidence of flow limiting CAD. This presentation is consistent with
Stress induced cardiomyopathy, where in onset of chest pain is usually triggered by emotional stress,
and investigations reveal nonobstructive CAD and apical ballooning of the myocardium. The patient was
started on beta blockers and two weeks later a TTE was repeated which now demonstrated complete
reversal of findings as compared to the study done two weeks ago. Apical akinesis had resolved and left
ventricular systolic function had improved to normal and was calculated at 72%.
DISCUSSION: Stress induced cardiomyopathy, also known as Tako-tsubo cardiomyopathy, transient
apical ballooning syndrome, or broken-heart-syndrome is a close mimic of acute myocardial infarction.
The clinical presentation including, symptoms of chest tightness, shortness of breath, elevated cardiac
markers and on occasion acute ST and T wave changes on EKG can often make the distinction between
the two disease entities difficult. The onset of symptoms due to stress induced cardiomyopathy is often
preceded by emotional or physical stress in approximately 66% of patients. TTE demonstrates transient
regional wall-motion abnormalities mainly at the apical segment, with a resultant ballooning of this
segment in systole relative to the other cardiac regions. Further, echo-graphic abnormalities resolve
within weeks. Percutaneous coronary angiography often demonstrates non-obstructive coronary artery
disease. The early use of coronary angiography as a diagnostic modality will inevitably lead to earlier
recognition and less inappropriate thrombolysis in the predominant elderly population.
248

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Manish P Shrestha, MD
A Case Report of Apical Hypertrophic Cardiomyopathy Mimicking Acute Coronary Syndrome.
Manish P Shrestha, MD Second Author: Vinod Khatri, MD Third Author: Karoon Nititham, MD Fourth
Author: Harvey Friedman, MD
INTRODUCTION: Apical hypertrophic cardiomyopathy (AHCM) is a form of non-obstructive
hypertrophic cardiomyopathy involving the left ventricular apex. Giant T wave inversions in the
precordial leads are the characteristic electrocardiographic findings. Extensive T wave inversions may
also be seen in coronary disease, particularly of the proximal left anterior descending artery, Brugada
syndrome, arrythmogenic right ventricular cardiomyopathy, subarachnoid hemorrhage, metabolic
abnormalities including hypocalcemia. Electrocardiographic changes in apical hypertrophic
cardiomyopathy are often confused with acute coronary syndromes. This may lead to unnecessary
investigation and inappropriate treatment. Invasive or non-invasive evaluation of the left ventricular
cavity is required to confirm the diagnosis. Unlike patients with hypertrophic obstructive
cardiomyopathy, patients with AHCM generally have benign outcomes in terms of cardiovascular
mortality. Morbid sequelae include diastolic dysfunction, left atrial enlargement with subsequent atrial
fibrillation, apical thrombi, ventricular aneurysms, ventricular arrhythmias, and myocardial infarction.
We present a case of apical hypertrophic cardiomyopathy in a Caucasian patient who was initially
diagnosed as acute coronary syndrome due to the findings of unexplained T wave inversions in the
anterolateral leads.
CASE PRESENTATION: A 71-year-old Caucasian man with a history of hypertension, dyslipidemia
presented to the emergency department with complain of epigastric abdominal pain and constipation
for 2 days. Pain was described as intermittent, crampy in nature associated with one episode of nonbloody
emesis. He denied any chest pain, shortness of breath, palpitation, dizziness/lightheadedness,
diaphoresis, fever/chills. His medications included lisinopril and simvastatin. His vital signs were within
normal limits. The physical examination of the patient was unremarkable except for epigastric
tenderness on deep palpation. Lab results (CBC, electrolytes, BUN, Creatinine) were unremarkable.12lead
EKG was performed as a part of routine investigation, which showed deep T wave inversions in
anterolateral leads. Cardiac markers were within normal limits. Patient was treated with antiplatelet
agents, beta-blocker and heparin. Cardiology service was consulted for possible acute coronary
syndrome( anterolateral ischemia). Upon review of old medical record, similar T wave changes were
seen in older EKG obtained 2 years ago. Stress test (adenosine myoview) done 3 years ago was normal.
Heparin, antiplatelet agents were stopped. Transthoracic echocardiogram was ordered, which showed
severe apical left ventricular hypertrophy. A final diagnosis of apical hypertrophic cardiomyopathy was
made.
DISCUSSION: When patients present with unexplained EKG repolarisation abnormalities, the diagnosis
poses a significant challenge. There is a wide differential diagnosis including apical hypertrophic
cardiomyopathy (AHCM). The consequences of missed diagnosis for a patient include unnecessary
investigation and inappropriate treatment. It is important to note that AHCM can mimic acute coronary
syndrome (ACS). However, an alternative diagnosis should always be considered in patients found to
have AHCM when symptomatic.
249

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Abhijai Singh, MD
First known case of FSGS in association with CML – Is it more than serendipity?
Abhijai Singh, MD
INTRODUCTION: A diverse group of glomerular lesions have been described in association with
hematological malignancies especially NHL and CLL. However chronic myeloid leukemia and nephrotic
range proteinuria remain a poorly defined association. We describe the first known case of Focal
segmental Glomerulosclerosis associated with CML in a young male.
CASE PRESENTATION: A 44 year old man was admitted with progressive fatigue, shortness of breath
and B symptoms. Examination revealed abdominal distension with splenomegaly and pedal edema.
Initial laboratory evaluation was remarkable for leucocytosis (188,500 /mm 3 with 89.9% neutrophils
with no peripheral blasts), anemia and thrombocytopenia. A FISH analysis revealed 97.8% interphase
nuclei containing an atypical BCR/ABL1 fusion signal pattern. A bone marrow biopsy was consistent with
CML with 3 % blasts.
His RFT showed a BUN of 9 mg/dl and creatinine of 1.2 mg/dl. He had 8.7 gm of proteinuria with
urinalysis negative for active sediments. A transjugular kidney biopsy was done due to
thrombocytopenia. On light microscopy, 3/10 glomeruli had widespread glomerular scarring involving >
80% of the tuft with a segmental appearance to the involved glomeruli. The tubules were atrophic in
50% of the cortex with intersititial fibrosis. Immunofluorescence studies were significant for 2+
mesangial deposits of IgM. Electron microscopy showed diffuse (75-90%) effacement of the foot
processes with normal endothelium and glomerular basement membrane. Kidney biopsy was consistent
with FSGS. Workup for known secondary causes of FSGS was negative
He failed initial treatment with Imatinib and was given a trial of Dasatinib in combination with
prednisone (1mg/kg). Six months on treatment, he had a partial cytogenetic remission (20% Ph
chromosome positive cells) but persistent proteinuria. Patient had a hematological relapse with blast
crisis (peripheral blasts rapidly increased from 30 to 91%), finally succumbing to his fulminant illness.
DISCUSSION: Six prior cases of nephrotic syndrome associated with CML have been reported in
literature so far with 4 having nephrotic syndrome at the time of diagnosis. The renal pathologies
described have included MPGN in 3, Membranous glomerulopathy in 2 and MCD in 1 patient. Our
patient represents the first case of focal segmental glomerulosclerosis associated with CML.
It is unclear at this point though, what role CML plays in initiation of the glomerular injury with
manifestation as nephrotic syndrome. However, response to TKI’s in some instances demonstrates the
implied role of PDGF in the pathogenesis.Rat models have aptly demonstrated that PDGF and bFGF are
selective mesangial cell mitogens leading to mesangial cell proliferation and extracellular matrix
accumulation, both harbingers of glomerulosclerosis
This case illustrates the first report of FSGS in association with CML, however, with insufficient evidence
to either suggest a serendipitous or a causative association.
250

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Naykky Maruquel Singh
Ospina, MD
Collagenomas : Common Skin Manifestation Of Multiple Endocrine Neoplasia Type 1 (Men1)
Naykky Maruquel Singh Ospina, MD Second Author : Evelyn Lacuesta
INTRODUCTION: MEN1 is a rare disorder that affects at least two different endocrine tissues within a
single patient. Most commonly the parathyroid glands, the anterior pituitary, and the pancreatic islets
cells. Skin manifestations, such as collagenomas are common in this patients and can help with the
diagnosis.
CASE PRESENTATION: A 39 year old man presented with recurrent episodes of abdominal pain and
nausea for the last three years. He had a history of primary hyperparathyroidism (PHP) treated with
parathyroidectomy 9 years before presentation. His examination was unremarkable with the exception
of epigastric tenderness and multiple pink round nodules of about 5-10 mm distributed diffusely
throughout his skin. His laboratory results were remarkable for a Lipase of 3 U/L, Calcium of 11 ng/mL
and elevated Parathyroid hormone levels. His CT abdomen revealed a hypervascular lesion in the
pancreas. His Prolactin level was 4700 mcg/L and a MRI of the brain showed a pituitary macroadenoma.
The findings of PHP, pancreatic tumor and pituitary macroadenoma were consistent with MEN1. His
pancreatic biopsy was consistent with a neuroendocrine tumor and his skin biopsy with collagenoma.
Lastly, DNA analysis showed a heterozygous mutation at intron 6 of the 11q13 chromosome.
DISCUSSION: MEN1 is a rare inherited syndrome characterized by the presence of hyperplasia and
neoplasia in at least two different endocrine tissues within a single patient. Patients with MEN1 most
often have tumors of the parathyroid glands, the anterior pituitary, and the pancreatic islets cells. The
most common and earliest manifestation of MEN1 is (PHP), which occurs in 95% of cases. Enteropancreatic
tumors occur in 30%–80% of patients and more than 50% secrete gastrin. Anterior pituitary
tumors occur in 15%– 90% of patients.
The gene for MEN1 is located on chromosome 11q13. It’s function is unknown, but it is postulated to be
a tumor suppressor gene. Patients found to have a mutated allele characteristic of MEN1 are not treated
until there is clinical evidence of a characteristic disease.
Our case brings up many interesting points. First, even though he had received definitive treatment for
his PHP it was again active upon admission. This reactivation occurs in about 50 % of the patients with
MEN 1. He had multiple pink round nodules on physical exam with histological findings consistent with
collagenomas. Cutaneous tumors are common in patients with MEN 1. Collagenomas are found in 60-70
% of the patients. Some authors believe they may help with presymptomatic diagnosis. Lastly, even
though his genetic testing was positive current guidelines recommend against routine screening of
family members since there is no therapy that can prevent MEN 1 manifestations.
251

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Soujanya sodavarapu, MD
Posterior Reversible Encephalopathy Syndrome Precipitated by an Energy Drink.
Soujanya sodavarapu, MD Girish Singhania, MD JOHN H PULA, MD, BHAGAT S AULAKH, MD MELISSA J
JOOS , NP
INTRODUCTION:PRES is likely caused by transiently impaired cerebrovascular autoregulation.
Hypertensive encephalopathy, eclampsia, and sepsis have been reported as the most common causes.
CASE PRESENTATION: A 36 year old male on fluvoxamine for obsessive-compulsive disorder presented
to the ER with the worst headache of his life. According to the patient, he drank a Finaflex N.O. Ignite
pre-workout drink and lifted weights prior to headache onset. His review of systems was positive for
nausea, vomiting, and photophobia, and negative for fever, neck stiffness, dizziness, chest pain, or
palpitations. His initial exam showed a blood pressure of 172/102, with no focal neurologic deficits or
optic disc edema. He had no history of hypertension. After an hour of observation in the ER, he vomited,
seized, became obtunded, and exhibited decerebrate posturing. He was intubated and loaded with
levitiracitam. Head CT was unremarkable. CBC, CMP, cardiac enzymes, urinalysis, anti-SM antibody,
SMRNP, SSA, SSB, SCL 70, anti-JO1, and ANA were all essentially normal. Lumbar puncture revealed
WBC-1(0-5/microliter), RBC-95(0/microliter), protein-50(12-60mg/dl), glucose-74(40-70mg/dl), gram
stain-negative. Brain MRI showed abnormal FLAIR signal in the subcortical white matter of the supra-
and infratentorial brain with areas of diffuse leptomeningeal enhancement. Twenty-four hours after
admission, he recovered to normal mental status and motor function, without further seizures, and was
extubated. His blood pressure normalized without medications. Seventy-two hours after admission, his
neurological exam was normal, and his only symptom was a mild headache. He was discharged on
depakote as a headache reliever, antiepileptic, and mood stabilizer. Two weeks after discharge, repeat
brain MRI showed resolution of the previously noted abnormalities. Based on his elevated blood
pressure at admission, presenting brain MRI appearance, and rapid clinical and radiographic
improvement, he was diagnosed with posterior reversible leukoencephalopathy syndrome (PRES).
Analysis of the ingredients in his pre-workout energy drink revealed the presence of caffeine and
theophylline. Severe drug interactions between fluvoxamine and theophyline have been reported,
including nausea, vomiting and seizures. The energy drink supplement he used can be purchased over
the internet, and advertises that it will “Make it Mind-Blowing” and “The stimulants will IGNITE your
workout and light you up”.
DISCUSSION: Our patient’s presentation is consistent with hypertension-induced PRES. What is novel
about our patient is that his elevated blood pressure was likely due to a pharmacological interaction
between two medications which had been previously reported as causing similar symptoms to PRES.
Although we have no data regarding prior cases, it is possible that the previously reported interactions
between theophyline and fluvoxamine of hypertension, seizure, and vomiting actually represented
hypertension-induced PRES. We highlight that PRES should be considered in cases of seizure and
encephalopathy, even without a typical predisposing cause, so proper treatment can be provided.
252

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muhammad Toor, MBBS
Though it sounded infectious
Muhammad Toor, MD Second Author: Sarvanan Pathanjali, MD Third Author: Danish Thameem, MD
INTRODUCTION:Most people will experience at least a single episode of backache in their life. While
such pain or discomfort can occur at any point in the back, the most common area affected remains to
be the lower back. Backache associated with fever includes a list of differentials which need to be
considered. Among these, infectious causes are particularly important due to high mortality.
CASE PRESENTATION: A 22-year old Caucasian gentleman was referred for the evaluation of a 5-day
history of non traumatic low back pain and fever. Backache was acute in onset, non radiating, dull in
character and of 4/10 in intensity. The pain increased with raising the lower extremities in supine
position. Fever was low grade and associated with night sweats. He was a non-smoker with no other comorbidities.
Physical examination revealed mild tenderness in the lower para-spinal region and no
neurological deficits. Laboratory data was unremarkable except white blood count (WBC) of 11100/ul,
C- reactive protein (CRP) of 177 mg/l and erythrocyte sedimentation rate (ESR) of 53 mm/hr.
Radiological investigations were unremarkable for any abscess or lymphadenopathy. MRI
abdomen/pelvis with contrast revealed thrombosis in the inferior vena cava and common iliac veins.
Widespread inflammatory changes surrounding these venous structures were compatible with acute
thrombophlebitis. A striking finding was an interrupted inferior vena cava and multiple collaterals
draining into supra hepatic circulation. The patient was started on anticoagulation with subcutaneous
enoxaparin. He was given no antibiotics and his urine and blood cultures were negative. His symptoms
resolved on anticoagulation and he was discharged on warfarin.
DISCUSSION: Absent inferior vena cava is a rare anomaly present in 0.3% of otherwise healthy
individuals. it is associated with idiopathic deep venous thrombosis, particularly in the young. Review of
the literature revealed that fever along with elevated inflammatory markers (WBC, ESR, and CRP) is a
common presentation. Computed tomography or preferably magnetic resonance imaging, are required
to delineate inferior vena cava anatomy and ascertain proximal extent of the thrombus. Although
invasive therapeutic modalities exist, long-term and commonly life-long anticoagulation is often
required.
253

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muhammad Toor, MBBS
A rare cause of acute mastitis.
Muhammad Toor, MD Second Author: James Kumar, MD
INTRODUCTION:Mastitis is the inflammation of breast tissue that may or may not be infectious in
etiology. Infectious mastitis is most commonly seen in lactating women. Though uncommon in nonlactating
women, streptococcus, pseudomonas and staphylococcus remain the main infectious causes.
When non-lactational mastitis does not respond to antibiotic therapy physicians should look for the
other causes like atypical infections or malignancy.
CASE PRESENTATION: A 50 year old female presented to the primary care physician office with the
complaints of left breast pain, redness and nipple discharge of 5-days duration. She was also
experiencing upper respiratory tract symptoms at the same time. Nipple discharge was cultured and she
was empirically started on azithromycin for upper respiratory tract symptoms. Over the course of next
two days, upper respiratory symptoms resolved but her breast pain and redness increased and extended
towards axilla. She presented to the emergency department with these complaints and was admitted
for administration of intravenous antibiotics and evaluation of non-resolving mastitis. After collection of
appropriate cultures intravenous vancomycin and intravenous metronidazole were started. Nipple
discharge cultures drawn as an outpatient did not grow anything in three days. USG of the breast was
negative for any abscess but showed multiple mildly dilated ductal structures in the subareolar and
periareolar region. Many of these ducts showed debris without any evidence of mass. These findings
were consistent with acute mastitis. With minimal improvement patient was discharged to home on oral
doxycycline and metronidazole with an outpatient follow-up. However over next two days, her
symptoms did not improve with oral antibiotics. On follow up, history was reviewed again and she gave
the positive history of cold sores in her husband. At that time, her antibiotics were stopped and oral
acyclovir was started suspecting mastitis to be of viral etiologies. Nipple discharge was obtained for viral
cultures. Her symptoms improved dramatically with this treatment and later cultures were reported to
be positive for herpes simplex virus type 1.
DISCUSSION: Herpes mastitis in non-lactating women is an extremely rare condition and it should be
suspected in the cases not responding to antibiotics. Only few cases have been reported so far in
literature. Exact mode of transmission is unclear though possible modes include autoinoculation from
the oral or genital lesions and transmission from close personal contact. In our case herpes was probably
transmitted from the close contact. Herpes mastitis should be considered in non-lactating women with
non-resolving mastitis and careful history focusing on the possible modes of transmission should be
obtained.
254

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Malvika Varma, MD
Hyperbaric Oxygen as a treatment option for Diabetic Myonecrosis
Malvika Varma, MD Tanvi Tiwari, MD Sunitha Nair, MD
INTRODUCTION: Diagnosing Diabetic Myonecrosis
CASE PRESENTATION: 31 year old female with type 1 diabetes mellitus presented with pain and
swelling of the right medial thigh since two weeks. There was no history of fever, trauma, joint pain,
joint stiffness or sensory loss. She had a similar episode two years ago involving both calf muscles
treated with rest and analgesics and took several months to resolve.
Past medical history was significant for type 1 diabetes, Grave’s disease, thyroid carcinoma post
thyroidectomy, and post-surgical hypothyroidism. She was non compliant with her medications which
included levothyroxine, NPH insulin and Lisinopril. Clinical examination was significant for low grade
fever and sinus tachycardia. Right lower extremity was edematous and extremely tender without
erythema or crepitus. The lower medial thigh was most tender without any fluctuant mass. There was
no swelling or stiffness of the knee and distal neurovascular function was intact. Muscle strength was
difficult to assess proximally due to severe pain but was normal distally.
Labs were remarkable for a mildly elevated white count, microcytic iron deficiency anemia and normal
renal function. Thyroid stimulating hormone was 105.6 and free T4 was 0.675. Total creatine kinase was
309. Glycated hemoglobin was 10.8%. Urine microalbumin to creatinine ratio was 330.7 suggestive of
occult nephropathy. Hypercoaguable workup was positive for lupus anticoagulant. ANA panel was
negative.
CT scan showed massive intramuscular, subcutaneous and fascial edema of vastus musculature
specially vastus medialis. Arterial and venous dopplers of the lower extremities were negative for DVT
and arterial occlusion.
She was initially treated with intravenous antibiotics, opioid analgesics. MRI done 48 hours later
confirmed the CT findings and now showed edema extending proximally into the pelvic muscles and
distally into the calf muscles. Needle biopsy of vastus medialis revealed acute inflammation and
hemorrhagic necrosis of the skeletal muscle consistent with diabetic muscle infarction(DMI) and she was
started on NSAIDs and aspirin.
A trial of daily hyperbaric oxygen treatment (HBOT) at 2.5 atmospheres absolute (ATA) was started after
informed consent. By the fourth treatment her symptoms were reduced by 50% and she was discharged
on day ten after 5 HBOTs, with remaining treatments scheduled as outpatient. Patient’s recovery was
gauged by symptomatic improvement.
DISCUSSION: DMI is a rare and under recognized complication of diabetes mellitus, characterized by
localized acutely painful inflammation and necrosis of muscles involving the extremities. It is typically
associated with long standing poorly controlled diabetes type1. Pathogenesis of the condition remains
unclear but largely involves muscle ischemia secondary to diabetic vasculopathy. Since the underlying
process in diabetic myonecrosis involves tissue ischemia, HBO could possibly play a crucial role in its
treatment.
255

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Rahul Wadke, MBBS
This time, the heart is really broken.
Rahul Wadke, MBBS, Bihn An Phan MD FACC
INTRODUCTION: Takotsubo cardiomyopathy (TTC), also known as stress induced cardiomyopathy or
apical ballooning syndrome or broken heart syndrome, is described in literature since 1990. It tends to
mimic acute coronary syndrome and most commonly presents as acute sub-sternal chest pain. The
diagnosis of TTC should be suspected in postmenopausal woman with chest pain, nonspecific ECG
changes, troponin elevation, cardiac imaging demonstrating apical ballooning, and absence of
obstructive CAD on angiography. Psychosocial or physical stressor typically precedes the development
of TTC. Despite its severity of presentation, majority of patients tend to have a favorable outcome.
CASE PRESENTATION: 85 year old female presented to emergency room with substernal chest pain
and acute onset shortness of breath from inpatient rehabilitation facility. She suffered an ischemic
stroke 4 weeks ago. On presentation she was hypoxic and hypertensive. Physical examination revealed
elevated JVD, crisp S1 & S2, no murmurs, and inspiratory crackles bilateral lung fields. 12 lead ECG
revealed normal sinus rhythm without ST segment alteration with elevation of troponin I levels. Medical
management was initiated for non ST elevation MI (NSTEMI). Hypoxia rapidly improved with Bipap.
With increasing cardiac markers and a new wall motion abnormality on transthoracic echocardiogram
(TTE), patient underwent cardiac catheterization. It revealed left ventricular ejection fraction (LVEF) of
55% with apical ballooning, and nonobstructive coronary artery disease. She was diagnosed with TTC.
After a day of improvement, patient had an episode of syncope, hypotension and hypoxia. She was
intubated for persistent hypoxia. Physical examination revealed a new III/VI holosystolic murmur at apex
radiating to axilla, elevation of JVD, and fine crackles across entire lung field. ECG remained essentially
unchanged. Cardiogenic shock required inotropic agents to maintain blood pressure. Pulmonary
embolism was ruled out as a cause of sudden decompensation, with CT chest . Emergency TTE revealed
LVEF of 65%, severely flail anterior mitral leaflet with ruptured chordae with severe mitral regurgitation.
These TTE findings were significantly different compared to previous TTE.
With multiple comorbidities, she was recognized as an extremely high risk surgical candidate for mitral
valve replacement. After discussion with cardiologist, cardiothoracic surgeon; patient’s family opted for
comfort care measures. Patient passed away peacefully with her close family by her side.
DISCUSSION: Even though mitral valve regurgitation (MR) is well documented with TTC, acute severe
MR secondary to chordae rupture has rarely been reported in the literature. This case represents an
opportunity to highlight rare but catastrophic complication in patient with TTC. A high level of suspicion
in patients with TTC who acutely decompensate will help in rapid diagnosis and possibly better
outcome. The exact mechanism of such a catastrophic complication still eludes us.
256

ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muralidhar Reddy
Yerramadha, MD
A rare case of Castleman’s disease in a patient with Sjögren’s Syndrome
Muralidhar Reddy Yerramadha, MD Correspondent author: S. Subramanian MD
INTRODUCTION:Castleman's disease, also known as angio follicular lymph node hyperplasia, is a rare
disorder. Castleman's disease is characterized by non-cancerous atypical lympho proliferation with two
types of presentation - unicentric and multicentric form. Unicentric Castleman's disease (UCD) presents
as a localized slowly growing mass with a relatively benign course where as multicentric Castleman's
disease (MCD) acts like lymphoma with more aggressive clinical course with diffuse lymph node
enlargement and systemic illness. It involves hyper proliferation of specific B cells that produce the
cytokine IL-6.
CASE PRESENTATION: A 47-year-old African American woman with known history of primary Sjögren's
syndrome diagnosed in 1993 and degenerative arthritis was admitted to our hospital for evaluation of
shortness of breath. Her previous history was significant for extensive recurrent lymph nodal
enlargement including cervical, mediastinal, and abdominal lymph nodes since 1995. Several of these
nodes have been biopsied with varying success. Pathology results showed reactive lymphadenopathy
with non specific findings. On current admission CT of the chest and abdomen revealed mediastinal
lymph adenopathy and a right perineprhic mass. Later, she underwent laparoscopic excision of the
perinephric mass, which was consistent with previous biopsy results. Immuno histochemical staining
revealed no monoclonal lymphocytes suggestive of lymphoma. As a result, a plan was made to follow up
in hematology clinic. Over the course of 6 months her performance status deteriorated, with worsening
shortness of breath, night sweats, weight loss, generalized body pains, and also left hip pain. MRI of the
hip showed significant bilateral iliac lymphadenopathy. Her CBC, BMP, Coombs, Immunoglobulin levels
and LDH were normal except elevated IL-6 levels. Later, her biopsy results from right iliac nodes
confirmed the diagnosis of hyaline vascular variant of MCD. She was started on chemotherapy and
prednisone every three weeks for four cycles. She responded very well to the treatment with
improvement in her performance status.
DISCUSSION: MCD is commonly associated with the human immunodeficiency virus and human
herpesvirus 8, and malignancies including Kaposi's sarcoma, non-Hodgkin lymphoma, Hodgkin
lymphoma, and POEMS syndrome where as in this case we discussed a very rare presentation of MCD
associated with Sjögren's syndrome. Most patients with MCD die of fulminant infections due to
immunosuppression, progressive disease or related malignancies. There is currently no standard therapy
for MCD. Castleman's disease is often undiagnosed or misdiagnosed. For this reason, only very few
patients have been reported and little information is available in the literature. It is important to
consider Castleman's disease in the differential when evaluating recurrent lymphadenopathy, as MCD if
left untreated usually gets worse and becomesincreasingly difficult and unresponsive to current
treatment regimens.
257

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Ben A Tritle, MD
Neuropsychiatric Sequelae of Hypoparathyroidism: A Case Report
Ben Tritle MD
INTRODUCTION: Intracranial calcification, particularly of the basal ganglia and cerebellar nuclei, is a
well documented complication of chronic idiopathic hypoparathyroidism. Importantly, these
calcifications can lead to neuropsychiatric manifestations such as movement disorders, delirium or
dementia, psychoses, and less commonly focal neurologic defects or seizure activity.
CASE PRESENTATION: A 55-year-old female patient with long standing history of idiopathic
hypoparathyroidism treated with calcitriol and unspecified dementia presented with acutely altered
mental status. Examination revealed a confused and disoriented patient, but no focal neurologic
abnormalities. Laboratory evaluation revealed a calcium level of 16.3 mg/dl and ionized calcium of 2.23
mmol/L. Head CT revealed symmetric, coarse calcifications within the basal ganglia, periventricular and
frontal lobe white matter, and cerebellar hemispheres. Correction of the patient’s serum calcium level
lead to improvement in her mental status back to her baseline dementia. Further investigation into the
medical record revealed this was the patient’s third admission in six months for severe hypercalcemia, in
addition to several episodes of profound hypocalcemia prior to that. Psychiatric evaluation under
normocalcemic conditions revealed the presence of auditory and visual hallucinations, episodes of
inappropriate laughter, and dementia. After psychiatric evaluation and discussion with family members,
it was determined that the patient’s dementia was advanced to such a degree that she was no longer
capable of complying with her calcitriol regimen, and arrangements were made to ensure proper
medication administration.
DISCUSSION: Here we present a case of a patient with a long-standing history of idiopathic
hypoparathyroidism with extensive intracranial calcification and neuropsychiatric
symptoms. Furthermore, evidence exists within the literature to suggest that presence of such
neuropsychiatric symptoms is directly related to the degree of intracranial calcification, which can be a
progressive phenomenon despite adequate control of serum calcium and phosphorous
levels 1,2 . Coupling that evidence with the report featured above, this case illustrates the necessity for
clinicians to be highly vigilant of the cognitive status in patients with idiopathic hypoparathyroidism
when prescribing vitamin replacements that, if taken incorrectly, can lead to severe metabolic
abnormalities.
1. 1. Kowdley KV, Couli BM, Orwoll ES. “Cognitive Impairment and Intracranial Calcification in Chronic
Hypoparathyroidism” Am J Med Sci. May 1993; 317(5): 273.
2. 2. Fulop M, Zeifer B. “Case Report: Extensive Brain Calcification in Hypoparathyroidism” Am J Med
Sci. Nov 1991; 302(5): 292-5.
258

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Jacques R Daoud, MD
SKIN RASH NINE YEARS AFTER RENAL TRANSPLANTATION
Jacques Daoud, MD, MS, Vera Marie Rosado-Odom, MD, Asif Sharfuddin MD, FASN, Raymond Johnson,
MD, PhD.
INTRODUCTION: In immunocompromised patients, a high index of suspicion is required in order to
identify diseases with atypical manifestations, as they can carry a high mortality rate if the diagnosis is
delayed or missed.
CASE PRESENTATION: A 42-year-old woman presented with a skin rash that started with a tender,
warm and erythematous nodule on her left thigh, and enlarged over the next 2 weeks, associated with
night sweats and a mild dry cough. She denied any recent travel, animal or bird exposure or new sexual
encounters. Her past medical history was significant for bronchial asthma and congenital dysmorphic
kidneys. Having received a deceased donor kidney transplant 9 years ago, her induction therapy
consisted of anti-thymocyte globulin, and her early post-transplant period was remarkable for two
rejection episodes. Her maintenance immunosuppression (IS) was cyclosporine, mycophenolate mofetil
and prednisone. Physical examination revealed a low grade fever, clear breath sounds, and mild graft
tenderness to deep palpation. An erythematous, nodular rash was noted on the thighs, knees, and right
forearm. The hospital course was complicated with shortness of breath and hypoxia that responded to
oxygenation and bronchodilators. Plain chest radiograph was unremarkable, while a chest CT revealed
numerous subcentimeter mediastinal nodes. A punch-skin biopsy from one of the newer migratory
lesions revealed yeast forms in the dermis suggestive of Histoplasma, confirmed by a positive urinary
Histoplasma antigen. The immuknow ATP assay value was very low in favor of profound
immunosuppression. Intravenous voriconazole was started followed by oral itraconazole. Three months
later, all cutaneous lesions had disappeared, and the cough had resolved.
DISCUSSION: Skin lesions are a very rare form of initial presentation of disseminated histoplasmosis.
Such manifestation may lead to misdiagnosis of a potentially fatal, otherwise treatable disease. The skin
biopsy helped quickly diagnose this disease, while IS was maximally reduced, and adequate levels of
antifungals ensured.
259

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Joseph Khalil, MD
What? No Ascending Paralysis?
Joseph Khalil, MD Second Author: Frank Hrisomalos, MD
INTRODUCTION:Guillain-Barre syndrome should be categorized as a group of syndromes with several
distinct subtypes. The common presentation of ascending paralysis is not essential for diagnosis and
may not even be present in a substantial proportion of patients.
CASE PRESENTATION: A 53-year-old male presented with a constellation of neurologic symptoms
following an acute giardial diarrheal illness treated with flagyl. Recent history included extensive
camping in Colorado and Kentucky, spring water ingestion, and multiple mosquito bites. Notable
findings included generalized weakness, hyporeflexia, severe lower back pain, bilateral posterior leg and
hand pains and paresthesias, perioral numbness, and dysautonomia including constipation, urinary
retention, and hypertension. Differential diagnosis was wide given this unique history and nonspecific
pattern of findings. Among the many conditions considered were an acute neurological process, acute
infectious process, flagyl toxicity, vitamin deficiency, and rare toxic exposure. A decision was made to
perform MR imaging of the CNS, lumbar puncture, electromyography, as well as obtain comprehensive
serum studies.
CSF studies revealed an albuminocytologic dissociation with a protein of 500 and a WBC of 10. EMG
showed prolonged distal latencies and slowed conduction. MRI showed enhancement of virtually all
exiting nerve roots of the thoracic spine as well as the cauda equina and conus medullaris. All viral
serologies and other serum assays were negative. We concluded that the patient displayed an atypical
presentation of Guillain-Barre syndrome. Notably, his autonomic instability and extremity
pains/paresthesias, classify his disease as a mixture of pure sensory and dysautonomic subtypes. The
patient’s symptoms improved with 5 days of IVIG. Symptoms were controlled and daily incentive
spirometry was performed. The patient’s respiratory status remained stable over admission without
need for respiratory support.
DISCUSSION: Our patient’s atypical presentation provides insight into the heterogeneity of this disease
and resulting diagnostic challenges that may arise. It is essential to recognize that Guillain-Barre
syndrome may often present without classic symptoms of ascending paralysis and areflexia. The astute
clinician must combine information gleaned from neuroimaging, electromyography, CSF and serum
studies, as well as a thorough history to diagnose the disease and rule out other possibilities within a
short time frame. Institution of Guillain-Barre specific treatment with IVIG or plasma exchange must be
done rapidly to minimize short term morbidity.
260

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Kapil A Mehta, MD
Crohn’s Disease and Shock in the Intensive Care Unit
Kapil A Mehta, MD, Mitchell Smith, MD; Andrew Williams, MD
INTRODUCTION: We present a case of a 29 year old female with history of Crohn’s disease on
azathioprine for 7 years who presented with flu-like symptoms for two weeks. Symptoms included
muscle and joint aches along with nausea and diarrhea. Her husband had experienced similar symptoms
during the same period of time; however, his symptoms resolved within a few days and her symptoms
continued. She became increasingly weak, developed a nonproductive cough and continued to have
fevers as high as 102.3F. One week prior to hospitalization, our patient was treated with clarithromycin
for her symptoms. This was followed by extremely watery diarrhea, and fevers. Upon presentation to
our hospital, she was in shock, delirious and admitted to the ICU.
CASE PRESENTATION: Physical exam revealed tachypnea, clear lung fields and a regular tachycardia,
without murmurs, rubs or gallops. No jugular venous distension was present. Non-pitting edema of her
bilateral lower extremities was noted. Palpation of the abdomen revealed a diffusely tender abdomen
with hepatosplenomegaly, voluntary guarding without rebound. There was presence of a diffuse
blanchable, maculopapular rash.
Pertinent laboratory evaluation showed: white blood count of 1.5 k/cumm, hemoglobin 8.7 g/dl and
platelet count of 59 K/CUMM, ANC was 900 k/cumm with 17% bands. Her LDH 1112 units/L,
haptoglobin

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Matthew M Nobari, MD
Painful, circular pretibial bumps: a case of post-streptococcal pharyngitis associated with erythema
nodosum.
Matthew M Nobari, MD Second Author: Nisha Sheth, MD Attending Author: Lannie Cation, MD
INTRODUCTION: A 30 year-old otherwise healthy Hispanic female presented to the clinic with a chief
complaint of bilateral lower extremity pain and rash for four days. One week prior to presentation, our
patient had a sore throat with no associated cough. About four days prior to presentation, she had an
abrupt development of pretibial pain and swelling bilaterally.
CASE PRESENTATION: On exam, this patient had no oropharyngeal abnormalities, including erythema
or purulent drainage and no adenopathy. On assessment of her lower extremities, erythematous
nodular lesions were noted. These lesions were circular, symmetrical and papulo-nodular, and some
were as large as three centimeters in diameter (photos available). They were exquisitely tender to
palpation and no discharge or fluctuance was noted. Laboratory testing obtained the same day revealed
an elevated erythrocyte sedimentation rate of 124 (0-20), an elevated anti-streptolysin O titer of 205 (0-
200), and a normal angiontensin-converting enzyme level of 41 (9-67). A chest-x ray was obtained,
which demonstrated no abnormal findings. Given her history of sore throat and elevated ASO titer, we
made a diagnosis of recent pharyngeal streptococcus infection with the delayed dermatologic
manifestation of erythema nodusum (EN).
DISCUSSION: Treatment for our patient consisted of non-steroidal anti-inflammatory drugs. Discussion
with an infectious disease specialist was done, and recommendations were to continue supportive care
with no antibiotic intervention for her resolved streptococcal infection. Her dermatologic lesions
resolved within one week.
Erythema nodosum is the most common form of panniculitis. The peak incidence of EN occurs between
18-36 years of age. Women are 3-6 times more likely to be affected than men. It is a rare dermatologic
finding sometimes associated with various disorders for which the specific pathophysiology remains
unknown. Examples of associated disorders include inflammatory bowel disease, sarcoidosis, Behçet’s
disease, drugs and various infections—with post-streptococcal infection being the most
common. Often, no cause is identified. Treatment is symptomatic and directed at the underlying
disease. We report a classic case of erythema nodosum associated with recent pharyngeal
streptococcus infection.
262

INDIANA POSTER FINALIST - CLINICAL VIGNETTE Andrew J Williams, MD
Complex Cranial Neuropathy Masquerading as Bell’s Palsy
Andrew J Williams, MD
INTRODUCTION: Bell’s Palsy affects the seventh cranial nerve alone, and true Bell’s remains idiopathic.
Other etiologies of seventh nerve palsy are not uncommon and may include more extensive pathology
including central lesions from ischemic disease or masses.
CASE PRESENTATION: An 81-year-old male presented to our Emergency Department with a threemonth
history of recurrent otitis media, managed conservatively and three weeks of right-sided facial
paralysis. Previous evaluation diagnosed Bell’s Palsy and he was treated with oral prednisone and
acyclovir. With worsening cough and no resolution of facial paralysis, he was re-evaluated.
Initial examination revealed a thin male with right facial paralysis. Further neurologic examination
revealed complex cranial nerve involvement including inability to wrinkle his forehead, absence of right
nasolabial fold, and facial droop on the right with inability to smile; all concerning for a lower facial
nerve lesion. Other right-sided findings included: trismus, decreased sensation in the trigeminal nerve
distribution, decreased corneal reflex, hearing loss indicating vestibulocochlear involvement, dysphagia
and inability to elevate the hemipalate, indicating compromise of the vagal nerve. He was unable to fully
shrug his right shoulder and had weakness turning his head, indicating involvement of the accessory
nerve as well. Other neurologic examination revealed no gross strength, tone or reflex abnormalities.
A non-contrast head CT was performed and demonstrated right mastoiditis but lacked details to fully
explain his cranial nerve involvement. Therefore, an MRI with focus on the internal auditory canals and
skull base was obtained. An extensive tumor involving the right aspect of the clivus bone, encasement of
the carotid and jugular vasculature at the jugular foramen, encasement of the right styloid process and
involvement of the hypoglossal canal was noted. Other imaging of his chest, abdomen and pelvis found
no evidence of metastatic disease. Differential diagnosis included head and neck cancers,
nasopharyngeal carcinoma, schwannoma, parotid tumor or lymphoma. Biopsy illustrated squamous cell
carcinoma.
DISCUSSION: Squamous cell carcinoma of the head and neck carries a poor prognosis and is
traditionally treated with surgical resection; however, skull base involvement, as seen in this case, is a
contraindication for attempted surgical intervention. Two-year survival rates with chemotherapy and
radiation outperform resection but survival is significantly reduced after two years. The patient’s
comorbidities limited his tolerance of chemotherapy and he was offered radiation alone.
True Bell’s Palsy is idiopathic. Recurrent, chronic otitis media or mastoiditis can cause a facial nerve
paralysis; however, this case revealed more complex cranial nerve involvement caused by a locally
invasive squamous cell carcinoma. For the general internist, this case emphasizes an appreciation and
skill of the physical examination remains the most important tool in their armamentarium.
263

IOWA POSTER FINALIST - CLINICAL VIGNETTE Nicholas L Hartog, MD
Hemophagocytic Lymphohistiocytosis Treated Without Immunosuppression
Nicholas L Hartog, MD Other Authors: Hilary Mosher, MD; Zuhair Ballas, MD
INTRODUCTION:Hemophagocytic lymphohistiocytosis (HLH) is an often-fatal immunologic disease that
can be primary (definitive genetic mutation) or secondary. Secondary HLH is a heterogeneous
disease. Viral infections are known triggers for either form. Other documented triggers of secondary
HLH are malignancy, autoimmune disease, infections, and drugs. HLH is a disease of dysregulated
immune activation. While primary HLH is treated based on the HLH-2004 protocol, there is currently no
consensus on treatment of secondary HLH. We present an immunocompetent patient with HLH
secondary to disseminated CMV successfully treated with valganciclovir.
CASE PRESENTATION: A 24 year-old African American male presented with 2 weeks of fever,
headaches, loose stool, and abdominal pain. Prior to onset of symptoms, he had been on a local
camping trip. Physical exam was significant only for a mildly tender abdomen, worst in the right upper
quadrant (RUQ). Admission workup included normal CSF studies, negative viral hepatitis panel, and an
abdominal CT and RUQ ultrasound notable for mild hepatomegaly. Labs on admission revealed elevated
AST/ALT (67 and 82 U/L respectively) and LDH (576 U/L). A thorough infectious disease workup,
including HIV qualitative and quantitative PCR, was negative. Patient was initially started on doxycycline
for concern for tick borne infections. On day 7, laboratory results revealed a CMV PCR that was 240,000
copies/mL and further worsening of liver function. The patient was also found to have nephrotic
syndrome without acute renal failure. Renal biopsy was consistent with minimal change disease. The
patients subsequent clinical decline lead to us reconsidering the diagnosis and current
treatment. Because of this decline with worsening hepatits, HLH was considered and serum ferritin
measured; it was elevated at 4179 ng/ml. Valganciclovir was initiated on day 8 of hospitalization.
Subsequent HLH-directed testing revealed hypertrigleridemia, elelvated soluble CD25, normal Natural
Killer (NK) cell activity and IL-1ra elevated at 5854 (normal

KANSAS POSTER FINALIST - CLINICAL VIGNETTE Karim Richard Masri, MD
Chronic Cannabis Use With Hyperemesis, Epigastric Pain And Conditioned Showering Behavior: A Case
Series
Karim Richard Masri, M.D. Ronnie Moussa, M.D., Heather Licke, M.D., Boutros El-Haddad
INTRODUCTION: This report promotes awareness to an emerging cannabis-induced syndrome that is
beguiling to primary care doctors and gastroenterologist specialists and a major expense on the
healthcare system.
CASE PRESENTATION: Four different young adults presented with recurrent admissions complaining of
intractable nausea, vomiting, and epigastric pain with an incidental finding of excessive showering. They
were all chronic heavy marijuana smokers. After extensive negative work up and observation of
symptomatic cessation upon the discontinuation of marijuana, a diagnosis of exclusion was determined.
DISCUSSION: Under the extrapolation of different animal model studies and basic science research, a
hypothetical mechanism may explain why these patients present with these characteristic symptoms.
The manifestation of chronic ?9-tetrahydrocannabinol (?9-THC) may not show until after a long time and
is reproducible when exposure to ?9-THC supersaturates the cannabinoid receptor-1 (CB-1). Chronic ?9-
THC exposure appears to desensitize the gabanergic effects of CB-1 which is known to cause intestinal
hypomotility, analgesia, and hypothermia. Extensive gastrointestinal workup is usually non-yielding and
may impose financial burden on the healthcare system.
265

KANSAS POSTER FINALIST - CLINICAL VIGNETTE Samuel Kilaho Akidiva, MD
RETROPERITONEAL COMPARTMENT SYNDROME
Samuel Kilaho Akidiva, MD
INTRODUCTION: Acute necrotizing pancreatitis is a disease with high mortality even in the best
practice settings. The patients who survive often have multiple different chronic complications some
requiring lifelong modifications to the survivor’s lifestyle. Key amongst these is diabetes, chronic
exocrine pancreatic insufficiency, and chronic renal failure. These complications may require
replacement therapy with enzymes, hormones, and renal replacement therapy. We highlight a cause of
potentially reversible renal failure in the setting of necrotizing pancreatitis.
CASE PRESENTATION: A 60-year-old Caucasian male presented having been treated previously at an
outside hospital after diagnosis of necrotizing pancreatitis three months prior. At presentation, he
complained of easy satiety and intractable nausea and vomiting. He was on scheduled dialysis 3
days/week. Examination revealed jaundice, cachexia, abdominal distention, and edema. Laboratory
showed bilirubin 6.2 (direct 4.2), prealbumin 11, alkaline phosphatase 1467, and glucose 214. Imaging
revealed extensive pancreatitis with pancreatic psuedocysts, dilatation of the intrahepatic ducts,
retroperitoneal inflammation, and normal kidney and ureters.
Surgery was performed for drainage of the pseudocyst. On incision, the contents of the pseudocysts
were found under intense pressure splashing across the operating room. Within minutes of drainage,
the patient who had been oliguric over the last 3 months started to make normal urine volumes. The
kidney function continued to improve and although the patient required dialysis on two occasions after
surgery. The creatinine stabilized at 1.5 and he has not required dialysis since.
DISCUSSION: Preventing any long term sequel of any disease process greatly improves patients’ quality
of life and also reduces healthcare utilization with its attendant costs and risks. In a similar setting, it is
important to consider this potentially reversible cause of renal failure and have timely intervention to
prevent chronic renal failure requiring lifelong dialysis.
266

KANSAS POSTER FINALIST - CLINICAL VIGNETTE Anup Kumar Kasi Loknath
Kumar, MBBS
Leukemoid Reaction And Autocrine Growth Of Bladder Cancer Induced By Paraneoplastic Production
Of G-CSF
Anup Kumar Kasi Loknath Kumar, MBBS, MPH Second Author: Jeffrey Holzbeierlein MD Third Author:
Peter VanVeldhuizen MD
INTRODUCTION:Granulocyte-colony stimulating factor (G-CSF) produced by nonhematopoietic
malignant cells is able to induce a leukemoid reaction by excessive stimulation of leukocyte production.
Expression of granulocyte-colony stimulating factor and its functional receptors have been confirmed in
bladder cancer cells. In vitro studies have demonstrated that granulocyte-colony stimulating
factor/receptor exhibits a high affinity binding and this biological axis increases proliferation of the
carcinoma. The clinico-pathological aspects, biology, prognosis and management of granulocyte-colony
stimulating factor secreting bladder cancers are poorly understood.
CASE PRESENTATION: A 39 year old Caucasian female with an invasive high grade urothelial carcinoma
presented with hematuria and low grade fevers. Labs revealed an elevated white blood cell count,
absolute neutrophil count and an elevated 24 hour urine protein. Upon further evaluation she was
found to have locally advanced high grade urothelial carcinoma without nodal or distant
metastasis. Serum Granulocyte-colony stimulating factor level was 10 times the normal limit. This led to
the diagnosis of a paraneoplastic leukemoid reaction. Her WBC count immediately normalized after
cystectomy but increased in concordance with recurrence of her disease.
DISCUSSION: This is one of the few cases reported that illustrates the existence of a distinct and highly
aggressive subtype of bladder cancer which secretes granulocyte-colony stimulating factor. Patients
presenting with a leukemoid reaction should be tested for granulocyte-colony stimulating
factor/receptor biological axis. Moreover, granulocyte-colony stimulating factor could be a potential
neoplastic marker as it can follow the clinical course of the underlying tumor and thus be useful for
monitoring its evolution. Neo-adjuvant chemotherapy should be considered in these patients due to the
aggressive nature of these tumors. With a better understanding of the biology, this autocrine growth
signal could be a potential target for therapy in future.
267

KANSAS POSTER FINALIST - CLINICAL VIGNETTE Sapna A Shah-Haque, MD
Neurosarcoidosis Presenting as Trigeminal Neuralgia
Sapna A Shah-Haque, MD, MBA Second Author: Sherri Braksick, MD Third Author: Ronnie Moussa, MD
Fourth Author: Boutros El-Haddad, MD
INTRODUCTION:Sarcoidosis is a granulomatous disease that primarily affects the pulmonary system,
but may also involve other organ systems. It is reported across all races, with a higher incidence among
African Americans. Neurological involvement in sarcoidosis is rare, with cranial nerve seven being the
most reported neurological finding. Trigeminal neuralgia, as presented in this case, is uncommon.
CASE PRESENTATION: A 38-year-old African American female, with a history of refractory trigeminal
neuralgia and pathologically confirmed cutaneous sarcoidosis, presented to the hospital for fifth cranial
nerve decompression of a suspected impinging vascular loop. She had failed medical therapy and
gamma knife treatment. Prior to surgery, magnetic resonance imaging revealed an enhancing mass of
1.5 cm x 0.6 cm x 1.1 cm in the left Meckel’s cave, which, when compared with prior imaging, was not
present. A partial craniotomy was performed, the mass was excised, and symptoms resolved. Frozen
pathological sections showed granulomatous inflammation consistent with sarcoidosis. Stains for acid
fast bacilli and fungi were negative, as were Quantiferon Gold and HIV serum studies. High resolution
computed tomography scan of the chest showed patchy infiltrates in the lungs suspicious for chronic
interstitial lung disease. She was dismissed home on a tapering dose of dexamethasone and follow-up
with a rheumatologist.
DISCUSSION: When a patient with a history of sarcoidosis presents with neurological symptoms,
neurosarcoidosis should be considered. Most cases are diagnosed at autopsy, indicating the prevalence
of this disease is higher than reported. Recognizing and correctly diagnosing neurosarcoidosis, though
rare, leads to treatment and decreased morbidity in patients.
268

KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Neil E Crittenden, MD
Acute Tapeworm Infection With Pulmonary Hypertension And Reactive Arthritis: First Reported Use Of
Polarized Light In Diagnosing A Pulmonary Parasite
Neil Crittenden, MD, Hanan Farghaly, MD, Forest W. Arnold, DO, MSc, Charlene K. Mitchell, MD, MSPH
INTRODUCTION: We report a challenging case of an acute tapeworm lung infection secondary to
hematogenous inoculation from a dog bite. The patient presented with dyspnea and knee pain and
diagnosis was aided by the first reported use of polarized light on both bronchoalveolar lavage (BAL) and
lung tissue specimens.
CASE PRESENTATION: A 29-year-old male presented with knee pain. He reported three
hospitalizations the prior month for dyspnea. He was diagnosed with eosinophilic pneumonia based on
an initial rapid resolution of his dyspnea and eosinophilia with steroids. Following the third
hospitalization, he required home oxygen and prednisone 60 mg daily. On admission to our hospital, he
complained of sudden knee pain and a 24-pound weight loss over 4 weeks. On exam, there was joint
tenderness of both knees without effusions, warmth, or erythema. Lung exam was clear.
Laboratory results showed a WBC count of 38,000 with 10% eosinophils; hemoglobin 12.7, an elevated
C-reactive protein of 5 (0-0.49 mg/dL) and IgE of 465 (=114 kU/L). The patient’s ANA, Rheumatoid
Factor, and HIV status were all negative. Plain x-rays of the chest and knees were normal. CT scan of
the chest showed a widened pulmonary artery trunk of 4 cm. An echocardiogram revealed a pulmonary
systolic artery pressure of 68 mmHg. The BAL was reported to have fungal spores and hyphae
suggestive of Candida. Thorascopic lung wedge biopsies revealed a diffuse perivascular interstitial
foreign body-type granulomatous reaction in all three lobes. Polarizable foreign material was found
diffusely within the granulomas and pulmonary arterioles, mimicking intravenous drug use. His stool
was positive for a parasitic ovum. He denied intravenous drug use. He recalled his dog had a diarrheal
illness during which she bit his finger, crushing the nail bed, prior to his illness.
The lung biopsies and fluid from his earlier BAL were reexamined. Using polarized light revealed
parasitic proglottids, a scolex and numerous primitive parasitic eggs originally identified as fungal
contaminants.
The patient was given a single dose of praziquantel 600 mg, which reversed his cor pulmonale symptoms
within days. His knee pain, consistent with reactive arthritis, also resolved. One month later, his
breathing had returned to baseline. Follow-up chest CT scan showed reduction of his pulmonary artery
trunk from 4 cm to 2.8 cm.
DISCUSSION: Acute hematogenous tapeworm inoculation with diffuse pulmonary perivascular
interstitial foreign body-type granulomatous reaction with pulmonary artery hypertension is an atypical
presentation. Our finding that use of polarized light can aid in identifying parasitic parts in lung
specimens has not previously been reported.
269

KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Ziad A Taimeh, MD
Tricuspid Valve Papillary Fibroelastoma Paradoxically Presenting with Transient Ischemic Attack: The
Diagnostic Intricacy.
Ziad A Taimeh, MD, John Loughran, MD, Marcus Stoddard, MD, Sumanth D. Prabhu, MD.
INTRODUCTION:Transient ischemic attack (TIA) is generally considered to be vascular in origin; caused
by thromboembolic disease of the carotid arteries or heart atria. Rarely, a primary cardiac tumor of the
left side of the heart may be the cause of cerebrovascular ischemia, such as TIA or stroke. Tumors of the
right side of the heart are usually asymptomatic. We present in this abstract a challenging case of
tricuspid valve fibroelastoma presenting with TIA and angina.
CASE PRESENTATION: A 60-year-old white male, with past medical history significant for diabetes
mellitus type 2, presented to our facility with multiple neurological complaints consistent with TIA and
dull substernal chest pain consistent with cardiac angina. He did not report any shortness of breath,
palpitations or loss of consciousness. He also did not have any dizziness, visual loss, or permanent focal
neurological deficits. His physical examination was unremarkable, as was his laboratory
workup. Cardiac enzymes were negative, and his electrocardiogram demonstrated sinus rhythm. The
patient was admitted for TIA and cardiac ischemia workup. Heart catheterization was negative for any
coronary artery disease, and carotid duplex imaging only showed mild non-obstructive disease of the
arteries. Computed tomography (CT) of the head was negative. On the other hand, CT of the chest
showed a 4.3 centimeter-in-diameter ascending aortic aneurysm, which had been stable for the past
few years. The transthoracic, and thereafter the transesophageal, echocardiograms showed a 1.65 x 1.2
x 0.9 centimeter mobile mass, attached to the anterior leaflet of the tricuspid valve. A patent foramen
ovale (PFO) was also evident. Blood cultures were negative and the patient showed no signs of
infection. He was subsequently taken to the operating room for an elective removal of the tumor, with
closure of the PFO. During the operation, a 1.7 cm yellow mass was excised, and the foramen ovale was
subsequently closed. No other masses were identified, and the tricuspid valve was patent postoperatively.
On further gross examination, the mass measured 1.7 x 1.1 x 0.6 cm, and was soft and pale
yellow, with gelatinous consistency. Microscopic sections showed multiple avascular branching papillae,
covered with benign endothelium. No evidence of myxoma or malignancy was identified. Postoperatively,
the patient did well with no recurrence of any chest pain or neurological deficits.
DISCUSSION: Papillary fibroelastoma of the right side of the heart is an extremely rare primary cardiac
tumor. Given the facts that this small tumor is frail and thrombotic, with catastrophic end results if left
untreated, imaging modalities need to be optimized, and more awareness needs to be implemented for
earlier diagnosis.
270

LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Shilpa Gadde, MD
Double Karma: Anti-GBM and ANCA (+) RPGN
Dr. Shilpa Gadde, Dr. Hitarth Dave, Dr. Shaminder Gupta, Dr. James Crowe, & Dr. Robert Perrett
INTRODUCTION: Type IV rapidly progressive glomerulonephritis is a rare form of glomerular insult and
injury. Its prevalence is 0.47 cases per million per year with a mean age of onset around 59. Mortality
and morbidity remains significant and requires close monitoring of the patient even during remission
stages. Renal manifestations of the underlying disease process was not evident after a renal transplant.
CASE PRESENTATION: 62 yr old Caucasian male with past medical history of hypertension,
cerebrovascular accident, C-ANCA (+) focal crescentic glomerulonephritis (diagnosed by a renal biopsy),
Anti-GBM antibodies, and hyperlipidemia presented with primary complaint of flank pain, greatest on
left flank, for a period of two days. Concomitant complaints were dysuria, hematuria, and dribbling. He
was nauseous, but denied chest pain, shortness of breath, hemoptysis, arthalgias or rashes. Patient was
compliant with his medications of Mycophenolate and Prednisone for his glomerulonephritis. On
presentation, his vitals were stable. Pertinent physical exam findings were only that of left flank
tenderness and bruising on bilateral ankles. Labs were abnormal for white count of 40.8, potassium of
5.5, BUN of 58, creatinine of 3.04 (elevated from his baseline), and GFR of 21 (lower from baseline).
Urinalysis revealed protein of 150, blood of 250, negative nitrites, leukocytes of 25, urine RBC>100, WBC
26-50, many bacteria. CT abdomen/pelvis only revealed perinephric fat stranding. Despite adequate
fluid resuscitation and renally dosed antibiotics, for presumed Pyelonephritis/UTI, BUN and creatinine
rose. A repeat renal biopsy showed necrotizing and crescentic glomerulonephritis and global
glomerulosclerosis, consistent with rapidly progressive glomerulonephritis. Immunofluorescence
staining revealed linear band-like deposition of IgG on the glomerular basement membranes, proving
Anti-GBM disease. In addition, concomitant high titer ANCA serology was evident in lab work. Thus the
two impending diagnoses of anti-GBM disease, likely Goodpasture’s, and ANCA (+), likely Wegener’s,
were entertained. As such, patient was appropriately started on plasmapheresis and Cyclophosphamide.
Simultaneously, pulse dose corticosteroids were started and continued. Despite treatment initiation of
above, patients’ creatinine and BUN continued to trend up and he subsequently required hemodialysis
prior to discharge.
DISCUSSION: Rapidly progressive glomerulonephritis, RPGN, is a diagnosis made when renal function
declines by more than 50% in under 3 months. Histopathological findings include crescent formation in
glomeruli. RPGN is divided into four subtypes based on glomerular injury. My patient had Type IV RPGN
which is a combination of Type I (Anti-GBM disease) and Type III (Pauci-immune, ANCA mediated).
Effective treatment is provided with corticosteroids, immunosuppressants, and plasmapheresis.
271

LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Justin D Fowlkes, MD
A twenty-five year old male with recurrent priapism
Justin D Fowlkes, MD and Jessica F Duncan, MD
INTRODUCTION: CASE PRESENTATION: A 25 year-old male was referred to our hospital for
evaluation of priapism, enlarged spleen, and elevated white blood cell (WBC) count. Within the
preceding 3 months, the patient had experienced two episodes of priapism and mild fatigue. On physical
exam severe splenomegaly was noted with the spleen crossing the midline and extending beyond the
pelvic rim. Complete blood count revealed a WBC count of 415,500 c/mm3, hemoglobin of 10.5 g/dL,
and platelet count of 535,000 c/mm3. The manual differential count included 2% promyelocytes, 27%
myelocytes, 15% metamyelocytes, 2% blasts, 10% basophils, and 5% eosinophils. Other pertinent
laboratory data included a creatinine of 1.45 mg/dL, uric acid level of 11.6 mg/dL, and lactate
dehydrogenase level of 577 u/L.
The patient was placed on intravenous fluids, allopurinol, hydroxyurea, and broad spectrum antibiotics.
After bone marrow biopsy, the patient underwent one session of leukapheresis. Bone marrow findings
were consistent with a diagnosis of chronic myelogenous leukemia (CML) in the chronic phase.
Fluorescence in situ hybridization revealed the BCR/ABL1 translocation product, confirming the
diagnosis of CML.
DISCUSSION: The incidence of CML is 1-2 cases per 100,000 persons, with priapism occurring as the
presenting complaint in only 1-2% of adult males diagnosed. High WBC counts, usually in excess of
300,000 c/mm3, can result in a hyperviscosity state that impedes blood flow. Initial treatment focuses
on lowering the WBC count with leukapheresis and chemotherapy. In patients newly diagnosed with
CML, current guidelines recommend that first line chemotherapy consist of one of the tyrosine kinase
inhibitors (TKIs) imatinib, nilotinib, or dasatinib. The landmark trial by S O’Brien and others in 2003 first
demonstrated complete cytogenetic response and major molecular response to the TKI imatinibmesylate
that were superior to standard of care at that time in chronic phase CML. Eight year follow-up
data reported in 2009 showed the durability of these responses with a tolerable side effect profile and
an estimated overall survival of 85%. In 2010, Saglio and colleagues compared nilotinib, a second
generation TKI, to imatinib. These newer TKIs may provide more rapid cytogenetic and molecular
responses.
We ultimately chose treatment with imatinib-mesylate based on its favorable long term follow-up data.
We also continued hydroxyurea for 6 weeks to control the WBC count. The main nonhematologic side
effects reported for first and second generation TKIs are superficial edema, nausea and diarrhea. At 8
week follow-up, the patient no longer experienced priapism, had no imatinib related side effects, and
had a major hematologic response.
272

LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Christian Mabry, MD
Acute Renal Failure in a Woman with Human Immunodeficiency Virus and Medication-induced Fanconi
Sydrome
Christian Mabry, MD and D. Luke Glancy, MD Medical Center of Louisiana in New Orleans, Louisiana
INTRODUCTION:Vertical transmission of HIV continues to be a serious health problem in developing
countries with over 95% of congenital HIV occurring in these areas. Most of these infected neonates
acquire the virus either during or near the time of delivery. The widespread use of highly active
antiretroviral therapy (HAART) has decreased this transmission rate from 25% (no treatment) to 2%. This
rate can be further decreased to less than 1% if prophylactic Cesarean section is performed in mothers
with viral loads greater than 1000. The potential complications of HAART should never outweigh the
benefits of starting this treatment as soon as the infection is found. Data from 2004 showed a 95%
decrease in perinatally acquired cases of Acquired Immune Deficiency Syndrome (AIDS) when the
appropriate preventive measures were taken.
CASE PRESENTATION: A 19-year-old female with congenital human immunodeficiency virus (HIV)
presented to the hospital with nausea, vomiting, diarrhea, and generalized fatigue for one week. Her
CD4 count at admission was 27. She had been taking a combination of Tenofovir, Lamivudine, and
Lopinavir/Ritonavir (Kaletra) over the previous two months for her viral infection. The patient was found
to have a creatinine of 1.6 (baseline 0.8 two months before), bicarbonate of 8, phosphorus of 3.4,
potassium of 5.5, and a chloride of 144. It was suspected that the patient had developed Fanconi
Syndrome from her Tenofovir treatment and required large amounts of fluid and electrolyte
replacement to normalize these values. Her acute renal failure resolved once Tenofovir was
discontinued and her clinical improvement mirrored the improvement in her electrolytes.
DISCUSSION: Tenofovir is a Nucleotide Reverse Transciptase Inhibitor which prevents replication of the
virus by competing for incorporation into its DNA. Fanconi Syndrome is a known complication of this
drug that occurs in about 1.6% of patients who use it. The nephrotoxicity of Tenofovir is due to
mitochondrial dysfunction. This causes a significant decrease in the energy used by the Na+-K+ pump in
the proximal tubules. This disruption allows for electrolytes and small molecules that would normally be
reabsorbed to be lost in the urine. The result is a proximal renal tubular acidosis with
hypophosphatemia, glucosuria, and aminoaciduria (Fanconi Syndrome). Fanconi Syndrome is a
complication of Tenofovir and should be monitored for in every HIV patient on HAART. The benefits of
this medication can be enormous but this success can be quickly erased if the clinician is not constantly
monitoring for signs of renal insufficiency.
273

LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Christian Mabry, MD
Nausea, Vomiting, and Diarrhea in a Patient with Hepatitis C and Acquired Immune Deficiency
Syndrome
Christian Mabry, MD, Charles V. Sanders, MD, and John J. Hutchings, MD Medical Center of Louisiana in
New Orleans, Louisiana
INTRODUCTION:Portal hypertensive gastropathy (PHG) is a somewhat common complication of
cirrhotic and non-cirrhotic portal hypertension. The mosaic-like pattern with intermittent red spots
seen on endoscopy was originally thought to be inflammatory in origin. It was not until the 1980s that
the disease was proven to stem from vascular ectasia and not erosive inflammation. This new
understanding of its pathophysiology explains why anemia is a common and life-threatening presenting
symptom. As the gastric mucosal blood flow responds to increasing pressures within the portal system,
there is both congestion and hyperemia within the stomach. Gastroenterologists are able to see these
changes on endoscopy and classify them as either mild or severe. Patients with known chronic hepatitis
C, like our patient, have been shown to develop PHG at a rate of about 13% per year and to have
progression of their gastropathy at a rate of about 6% per year.
CASE PRESENTATION: A 42-year-old male with a past medical history of HIV/AIDS (his most recent CD4
count, 4 months before admission, was 19) and hepatitis C presented to the Emergency Department
complaining of 1 week of persistent nausea, vomiting, and diarrhea. He stated that he had been
vomiting approximately 2 to 3 times per day but denied any blood in the vomitus. His admit labs were
as follows: hemoglobin of 11.8, hematocrit of 35, total white blood cell count of 3.9, total protein of 6.0,
albumin of 1.6, total bilirubin of 2.3, aspartate aminotransferase (AST) of 141, alkaline phosphatase
(ALP) of 146, and alanine aminotransferase (ALT) of 31. A presumptive diagnosis of gastritis was made
based on clinical presentation and broad-spectrum antibiotics were started. Computed tomography
(CT) images of the abdomen and pelvis with contrast were obtained and showed diffuse, severe gastricwall
thickening, consistent with edema. An esophagogastroduodenoscopy (EGD) was then performed
and a diagnosis of portal hypertensive gastropathy was made.
DISCUSSION: Imaging is not the preferred choice for diagnosing PHG when compared to direct
endoscopic visualization. A study designed to verify this concluded that computed tomography can
detect portal hypertensive gastropathy with a sensitivity of 75% and a specificity of 89%. In that same
study, CT was also specific enough to exclude the diagnosis of PHG in all 92 control patients who were
free of the disease. In light of these study results and the progression to diagnosis in our patient, we
conclude that CT can be an effective means of aiding the diagnosis in the appropriate clinical setting.
274

LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Abhishek Seth, MD
Diabetic Ketoacidosis induced Hypertriglyceridemic Acute Pancreatitis treated with Plasmapheresis –
“Recipe for Biochemical Disaster Management”
Abhishek Seth, MD Saurabh Rajpal, MD L Keith Scott, MD
INTRODUCTION: Hypertriglyceridemia is the third most common cause of acute pancreatitis
constituting 1-38% of cases of pancreatitis presenting to the hospital. Diabetic ketoacidosis (DKA)
induced hypertriglyceridemia causing pancreatitis is an interesting phenomenon and has rarely been
reported in literature.
CASE PRESENTATION: 40-year old African American male with a past medical history of diabetes
mellitus, hypertension, dyslipidemia, and recurrent pancreatitis s/p distal pancreatectomy presented
with worsening abdominal pain and vomiting. The patient was found to be in DKA and was admitted to
the medicine intensive care unit. On blood draw he was found to have milky plasma. He had a
triglyceride level of 4854 mg/dl and serum lipase of 8223 U/L. CT scan revealed severe acute
inflammatory change and edema of the residual pancreas. The patient received one session of
plasmapheresis for 4 hours after which the triglyceride level decreased to 629 U/L. Patient’s symptoms
resolved after plasmapheresis and treatment of DKA. Subsequent stay in the hospital was uneventful
and the patient was discharged on gemfibrozil for hypertriglyceridemia. The patient is being investigated
for congenital hyperlipidemias, the results of which are still pending.
DISCUSSION: Insulin deficiency leading to lipolysis coupled with inhibition of lipoprotein lipase in
peripheral tissues results in hypertriglyceridemia in DKA. The mechanism by which hyperlipidemia leads
to pancreatitis is less well established but a toxic role for accumulated free fatty acids in the pancreatic
tissue has been suggested. Small studies have shown that DKA is associated with coexisting pancreatitis
in about 10-15% of the cases of which hypertriglycerdemia is an identifiable factor. Plasmapheresis is
well known treatment modality for hypertriglyceridemia induced pancreatitis and had excellent results
in our patient.
275

MAINE POSTER FINALIST - CLINICAL VIGNETTE Karen Elizabeth Bascom, MD
A Numb Chin and A Big Prostate: An Unusual Presentation of Lymphoma
Karen Bascom, MD, Resident, Maine Medical Center, Portland, ME.
INTRODUCTION:Lymphoma is a common malignancy with many subtypes and varied presentations.
This case highlights the unusual ways in which lymphoma can present and the importance of having a
high index of suspicion for malignancy in the out patient setting.
CASE PRESENTATION: A 39 year old Caucasian male presented to the Emergency Department with a
numb chin and back spasms. The patient presented initially to his Primary Care Provider (PCP)
complaining of hesitancy and nocturia. An enlarged prostate was found on exam and the patient was
started on tamsulosin without improvement in his symptoms. He subsequently presented complaining
of left sided chin numbness. This was evaluated by a dentist, dental surgeon and neurologist and no
apparent cause was found. On the morning of presentation the patient developed bilateral chin
numbness and left tongue flaccidity. In addition he was experiencing diffuse muscle spasms which
prompted him to present to the Emergency Department for evaluation. Review of symptoms was
pertinent for significant weight loss and night sweats. On physical exam the patient was mildly
hypertensive. Neurological exam revealed numbness of the chin, deviation of the tongue to the left on
protrusion, and flaccidity and loss of fissures of the left side of the tongue. Prostate exam demonstrated
a symmetrically enlarged, boggy prostate which was non tender to palpation. Complete blood count and
complete metabolic panel revealed a mild leukocytosis, anemia with a normal MCV and a mild
transaminitis. MRI of the mandible showed a small signal abnormality with the left hemimandible. CT of
the abdomen demonstrated bilateral adrenal masses, multiple liver lesions and retroperitoneal lymph
nodes. Biopsy of the prostate and bone marrow returned with B cell lymphoma, with features
intermediate between large B cell lymphoma and Burkitt's lymphoma. The patient was started on R-
CHOP chemotherapy with intrathecal methotrexate prophylaxis. Unfortunately after five cycles of
chemotherapy the patient represented with altered mental status and was diagnosed with
lymphomatous carcinomatosis. He died of complications of lymphoma less than six months after his
diagnosis.
DISCUSSION: This case illustrates an uncommon presentation of a common illness. Although the
symptom of a numb chin is an unusual complaint it is well documented as a manifestation of underlying
malignancy and has been explained by varied mechanisms including paraneoplastic syndromes and local
compression of nerves. Prostatic lymphoma is rare but should be considered in patients with obstructive
uropathy or an abnormal rectal exam, especially in patients with a prior history of lymphoma.
276

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Tanyaporn Wansom, MD
MPP
Hemophagocytic lymphohistiocytosis and Disseminated Tuberculosis: Making a dual diagnosis
Tanyaporn Wansom, MD, Geoff Connors, MD, Satish Shanbhag, MBBS, MPH
INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of immunological
activation resulting in multi-organ accumulation of histiocytes and lymphocytes which phagocytose
other cell lines. Although the familial form is commonly seen in infancy, a secondary form can be seen in
adults typically triggered by infection, malignancy, immunodeficiency or rheumatologic disorders. Rapid
diagnosis is crucial, as HLH is usually fatal if untreated.
CASE PRESENTATION: A 69 year old woman with hypertension and hypothyroidism was admitted for a
six-month history of progressive bilateral lower extremity weakness that had rendered her unable to
walk. She had immigrated to the US from the Philippines over forty years ago and was a retired
schoolteacher. Her laboratory values on admission were notable for hemoglobin of 7.9%, sodium of 129,
corrected calcium of 12.4, and creatinine of 2.5. During the course of her hospitalization, she developed
high fevers, pancytopenia, disseminated intravascular coagulation, and gastrointestinal bleeding,
ultimately culminating respiratory failure requiring intubation. Pleural fluid analysis from bilateral
pleural effusions revealed an exudate; cytology showed reactive histiocytes and lymphocytes without
atypia. Despite treatment with broad-spectrum antibiotics, the patient continued to be
febrile. Rheumatologic workup, hepatitis serologies, HIV, RPR, were negative. Blood, sputum, and urine
cultures were also negative; AFB smears of sputum and CSF were negative. PET scan showed FDG-avid
retroperitoneal, mediastinal, left supraclavicular, and external iliac adenopathy. Lymph node biopsy was
delayed secondary to coagulopathy. Bone marrow biopsy showed granulomatous inflammation,
markedly increased histiocytes throughout the marrow space and several foci of hemophagocytosis.
With improvement of her coagulopathy, lymph node biopsy was performed, revealing widespread
necrosis superimposed on granulomatous inflammation. AFB smears of lymph node tissue were
positive; the patient was empirically started on four-drug therapy for Mycobacterium tuberculosis
(MTB). Lymph node and sputum cultures eventually grew MTB. A diagnosis of HLH was made as the
patient met diagnostic criteria including fever, pancytopenia, hypertriglyceridemia, hyperferritinemia,
transaminitis, and hemophagocytosis on bone marrow biopsy. As HLH was secondary to MTB, no
immunosuppressive therapy was instituted while awaiting response to anti-tubercular therapy. With
treatment of her MTB, the patient clinically improved over weeks and was extubated successfully.
DISCUSSION: This case underscores the importance of keeping reactivation of latent TB on the
differential for patients presenting with the appropriate history, even if TB exposure occurred decades
prior. Because mycobacteria often take weeks to culture, a high index of suspicion and AFB smears of
tissue can aid in early diagnosis. Secondary HLH is an uncommon, but often fatal sequelae of TB or
other infections,and can mimic sepsis.
In a 2006 review of HLH and TB, mortality was 50%, independent of therapy given. In the event of failure
of anti-microbial therapy, a combination of immunosuppressants and cytotoxic chemotherapy should be
instituted for patients with secondary HLH; a missed diagnosis is invariably fatal.
277

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Kathy L McGill, DO
Chapter Winning Abstract: A Case of Progressive Multifocal Leukoencephalopathy after Receiving a
Monoclonal Antibody
Kathy L Mcgill, DO and Barbara A Neilan, MD
INTRODUCTION:Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection
usually related to HIV and AIDS. PML rarely occurs in other immunosuppressant settings. This is a report
of a female whose cutaneous T-cell lymphoma was treated with a monoclonal antibody and who
subsequently developed progressive multifocal leukoencephalopathy. We report this case to educate
clinicians about this rare disease so it can be diagnosed in a timely manner
CASE PRESENTATION: Ms. M, a 38 year old female, was diagnosed with cutaneous T-cell lymphoma in
2008. Due to disease progression she was treated with various agents over these three years including
methotrexate, Targretin, Folotyn, Ontak, and radiation therapy. Most recently she received 2 doses of
brentuximab with excellent cutaneous response.
Several days after receiving her 2 nd dose of brentuximab she developed difficulty with reading numbers,
specifically reading her credit card number over the phone. She also developed problems with word
finding and ataxia.
Neurological exam revealed a patient who was awake and alert but who had significant cognitive
deficits. She followed most commands; however, she was slow in doing so. Her speech was
understandable, but she answered questions incorrectly about 90% of the time. Her right pupil was
slightly larger than her left pupil but both pupils were reactive to light. Cranial nerves II through XII were
grossly intact. Her strength was 4/5 bilaterally
A MRI showed multiple cortical and white matter lesions within the supratentorial and infratentorial
parenchyma with mild associated edema and a mild degree of tonsillar herniation. The patient
underwent a brain biopsy with pathology revealing JC virus.
Further brentuximab dosing has been avoided. She was discharged home and is improving
neurologically.
DISCUSSION: By adulthood, 86% of individuals test positive for antibodies against the JC virus. In
asymptomatic individuals the JC virus lies dormant in the kidneys and lymphoid tissue. However, when
a person becomes immunosuppressed the JC virus becomes activated and disseminates to the brain.
Once in the brain the virus infects oligodendrocytes causing cell lysis, demyelination, and PML. Mortality
is high with a median survival time of 3 months in patients without HIV.
Brentuximab, a monoclonal antibody against CD30, was recently approved by the FDA for treatment of
anaplastic large cell lymphoma. The temporal relationship between the administration of brentuximab
and the patient’s onset of PML suggests a causal association between the two. The brentuximab
possibly suppressed her immune system allowing activation of the JC virus and subsequent PML. One
confirmed case of PML associated with brentuximab therapy was reported during clinical trials. Other
monoclonal antibodies such as natalizumab, efalizumab, and rituximab have also been associated with
PML.
278

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Shan Shan Chen, MD
Successful Treatment Of Myeloma Cast Nephropathy With Plasma Exchange And Chemotherapy
Shan Shan Chen, MBBS.Others: Tamil Kuppusamy, MD, Moon Shan Lui, MBBS
INTRODUCTION: Myeloma cast nephropathy is the most common cause of severe renal failure in
patients with multiple myeloma. Studies have revealed that early reduction of serum free light chains
(FLCs) can facilitate renal recovery, which can lead to significant survival benefits. Principal treatment
modalities to reduce FLCs include 1) diminished production rates by effective chemotherapy 2) direct
removal of FLCs from serum by plasma exchange (PLEX) or high cut-off hemodialysis. However, there are
no clear treatment guidelines for cast nephropathy and literature discrepancies exist for the role of
PLEX.
CASE PRESENTATION: We present the case of a 64-year-old female with hypertension and worsening
renal failure. She denied using NSAIDs or diuretics. Laboratory results were notable for a urinalysis with
2+ protein and 1+ blood as well as serum and urine immunofixation electrophoresis studies positive for
lambda light chains. A renal biopsy was consistent with lambda light chain cast nephropathy, diffuse
acute tubular injury and acute interstitial inflammation. The bone marrow biopsy demonstrated a
plasma cell neoplasm with 60% lambda light chain restricted plasma cells. A fluorescent in situ
hybridization panel revealed positivity for monosomy 13 in 8.8% of the cells and 3 copies of 1q21,
including CKS1B which are adverse prognostic indicators. The patient subsequently underwent
treatment with five sessions of PLEX concurrently with dexamethasone. This was followed by a
chemotherapy regimen of dexamethasone, bortezomib and cyclophosphamide. After one course of
PLEX, serum FLCs and 24-hour urine lambda light chain decreased by 80% in 24 hours and then by 99%
45 days later. Renal function improved from a serum creatinine of 4.5 mg/dl at the time of diagnosis to
2.9 mg/dl after 45 days.
DISCUSSION: We present a case of lambda light chain cast nephropathy successfully treated with PLEX
and high dose dexamethasone followed by bortezomib-based chemotherapy. Although a randomized
control trial by Clark et al. suggested no substantial benefit of PLEX for acute kidney injury in patients
with multiple myeloma, renal pathology was not verified by biopsy in their trial. In Pozzi et al. study, only
66.67% of 24 patients had myeloma kidney when renal biopsy was performed, suggesting not all of the
multiple myeloma patients presenting with acute kidney injury had myeloma cast nephropathy. Leung
et al. demonstrated the relationship between renal recovery and free light chain reduction was present
only in biopsy proven cases of myeloma cast nephropathy. Hutchison et al. study also recommended
direct removal of FLCs from serum as an option for patients with biopsy-proven myeloma kidney. While
our patient’s recovery may have been coincidental, further study with biopsy-proven cases is required to
further delineate the role of PLEX in myeloma cast nephropathy.
279

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Stefan David, MD
3 cases of negative pressure pulmonary edema: an acute, potentially lethal post-anesthesia
complication
Stefan David, MD Venkataraman Palabindala, MD, Smriti Manandhar, MD, Rajesh Tota-Maharaj, MD,
San Thida, MD, Surendra Marur, MD, MPH, FACP, and Brian Bohner, MD
INTRODUCTION: Negative pressure pulmonary edema (NPPE) represents a potentially fatal condition
characterized by rapid intraalveolar fluid accumulation occurring in post-anesthesia setting. Prevalence
is less than 0.1%, but it may be underreported.
Two NPPE types are described. In type I NPPE, inspiration against an upper airway obstruction reduces
the intrathoracic pressure and results in fluid extravasation. Type II NPPE occurs in patients with chronic
obstruction resulting in PEEP. Once the obstruction is removed, a relative state of negative pressure
results in intraalveolar flooding. If properly recognized and treated, NPPE has an excellent prognosis
CASE PRESENTATION: We are hereby reporting 3 cases of young patients with acute pulmonary
edema developed status post extubation:
-21 years old (yo) African American man, with history of asthma, hads general anesthesia for dental
abscess drainage and molar extraction became hypoxic after extubation (SaO2 78%). The patient
received high flow oxygen via mask and was transferred to ED. Chest XRay (CXR) revealed diffuse
bilateral infiltrates suspicious for pneumonitis or noncardiogenic pulmonary edema. CT angiogram (CTA)
excluded pulmonary embolism (PE). Echocardiogram revealed normal left ventricular function and mild
right ventricle (RV) dilation and hypokinesis The patient received Oxygen supplementation via Venturi
mask and 40mg of Lasix iv, with subsequent gradual improvement and CXR normalization in three days
after admission
-30 yo previously healthy African American woman developed hypoxic respiratory failure with high A-a
gradient after abdomino-plasty and liposuction. After extubation the patient had rales and her oxygen
saturation dropped. After administering 20mg of lasix iv, the patient was transferred to ED. CXR
revealed bilateral infiltrates. CTA showed no evidence of PE. Echocardiography revealed normal
ventricular motion and filling. Patient was placed on BiPAP (15/5, with FiO2 50%) with gradual
improvement occurring overnight ( SaO2 reached 100% on room air and pulmonary infiltrates clearing
on CXR).
-27 years old African American woman extubated after liposuction, became hypoxic (SaO2 40%) once
extubated after liposuction. . The patient received 40mg Lasix iv and high flow oxygen prior to ED
transfer. CXR showed extensive pulmonary infiltrates. Additional 60mg of lasix were administered
(followed by 3.8L diuresis) and the patient was placed on BiPAP with subsequent gradual rapid recovery.
The patient also had a history of snoring, suggestive of obstructive sleep apnea and subsequent
pulmonary hypertension, known augment the risk of her NPPE
DISCUSSION: Our cases emphasize that physicians should be aware of NPPE - an underreported postanesthesia
event, occurring in young patients. Although rare, NPPE may be lethal, if not properly
recognized and treated. Correct diagnosis may avoid further unnecessary tests.
280

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Ezza Aslam Khan, MBBS
Acute psychosis as a manifestation of Lyme disease
Ezza Aslam Khan,MD Other : Helen Gordon, MD
INTRODUCTION: Borrelia Burgdorferi can involve the nervous system in 10-15% of cases of Lyme
disease. Neurological, cognitive and psychiatric symptoms occur in the later stages of the disease. We
present a case of neurological Lyme, presenting as an episode of acute psychosis.
CASE PRESENTATION: Ms. W, a 28 year old female with no significant past history, had been having
paraesthesias of various parts of her body for a few months, lasting a few minutes, recently diagnosed
with depression with difficulty concentrating. During current episode, symptoms once again began with
paraesthesias, followed by drooling from left side of her mouth and blurring of vision. She developed
extreme agitation, became combative and had to be held down by 5 people. She was given olanzapine
for sedation. Several hours later, patient had no recollection of this psychotic episode. She continued to
be drowsy and lethargic. An electroencephalogram was consistent with diffuse encephalopathy.
Previously, she was admitted with similar neurological complaints without psychosis, a CT scan,
MRI/MRA was negative. Repeat imaging on this admission were also negative as was urine toxicology for
illicit substances. Since patient was residing in a Lyme endemic area serologies were done which were
positive, later confirmed by western blot. An LP was done in light of neurological complaints and was
consistent with aseptic meningitis. Patient completed 3 weeks of IV ceftriaxone following which her
symptoms significantly improved.
DISCUSSION: Borrelia Burgdorferi is known to affect the nervous system. In the acute setting,
symptoms of meningitis and cranial neuropathy are well documented. In the sub-acute and chronic
settings, symptoms can be neurological, cognitive or psychiatric. If there is no clear cut history of a tick
bite, rash, joint pain or a flu-like illness, diagnosis can often be missed.
Conclusion: Neuroborreliosis has varied presentation. In endemic areas, prior to diagnosing a patient
with a psychiatric condition it is important to rule out Lyme disease.
281

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Nyan L Latt, MD
Flood’s Syndrome: a desperate case of ruptured umbilical hernia in a patient with cirrhosis and ascites
Nyan L Latt, MD Stefan David, MD Bharath Alamelumangapuram, MD Surendra Marur, MD, MPH, FACP
David Saltzberg, MD
INTRODUCTION: Ascites results in abdominal distension and weakening of the abdominal wall. 20% of
patients with both cirrhosis and ascites develop umbilical hernias. Flood’s Syndrome, represented by
umbilical hernia rupture with subsequent loss of ascitic ascitic fluid is a rare, under-reported event
associated with 30% mortality rate.
CASE PRESENTATION: A 58-year-old woman with advanced cirrhosis (MELD score 19) and recurrent
ascites refractory to paracentesis and diuretics, presented with drainage of large amounts of serous fluid
from her umbilicus after scratching the area earlier. Ascitic fluid drainage could not be controlled, so she
came to emergency department. Prior to being diagnosed with cirrhosis, the patient was in good health.
Liver biopsy showed evidence of cirrhosis, but could not define any specific etiology. Hepatitis B and C
serologies were negative. Non-alcoholic fatty liver disease was considered the most likely cause of the
patient’s cirrhosis.Family and social history is non-contributory.
Physical examination revealed scleral icterus, dry mucous membranes and distended abdomen with
massive ascites. Laboratory studies on admission showed hematocrit of 31.6, platelet count of 85,000
and white count of 4900. PT was 17.0 with an INR of 1.31.
During hospitalization, the patient received IV fluid hydration. It was reported that 3 liters of ascitic fluid
was drained spontaneously into the collection bag attached to the abdominal wall defect when she sat
up. The patient was therefore transferred to a university medical center where she had an emergent
surgical repair of the umbilical hernia rupture. Unfortunately, post-operative care was complicated and
the patient died from septic shock.
DISCUSSION: We describe the unfortunate case of a patient with Flood’s syndrome (i.e.: umbilical
hernia rupture secondary to uncontrolled ascites that resulted in the thinning of the abdominal wall). In
these cases surgical repair is complicated not only by the fragility of the abdominal wall, but also by the
protein depletion due to ascitic fluid loss, superimposed on poor nutritional status secondary to
cirrhosis.. In addition to protein loss and hypovolemia, infection is a frequent, life-threatening
complication. Timely intervention to reduce portal hypertension (e.g. by TIPS), despite its complications,
may prevent this late desperate development occurring in uncontrolled ascites.
282

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Hui Peng, MD
Stiff–Person Syndrome
Hui Peng, MD Jennifer Dearborn, Xian Yan, Steve Ayres, Venkataraman Palabindala, Bharath
Alamelumangapuram, William Hagopian, Arun Venkatesan
INTRODUCTION: Stiff-person syndrome (SPS, previously stiff man syndrome) is an extremely rare
(fewer than 1 per million) neurological disorder which involves severe stiffness and profound muscle
spasms and highly associated with diabetes mellitus. The pathogenesis of SPS is a highly specific
antibody against the 65-kDa isoform of glutamic acid decarboxylase (GADA), which is involved in
gamma-aminobutyric acid transmission. This antibody is present in approximately 60 percent of
patients.
CASE PRESENTATION: A 47 year old Caucasian woman with a 10 year history of muscle spasms,
difficulty walking and performing daily activities. She started falling due to muscular rigidity initially, and
has been walking on her tip toes secondary to contractures. Her significant muscle spasms with pain are
in her legs and her back. A variety of diagnoses including stress disorder, dystonia, radiculopathy and
myopathy were previously postulated. Recently she was diagnosed with diabetes without ketoacidosis
and well controlled with metformin. She was admitted to the neurology service due to poor
symptomatic control by benzodiazepines and balcofen and failure of intravenous immunoglobulin (IVIG)
monthly for 1 year at home (3 consecutive days). Physical examination showed significant lordosis and
contraction of the paraspinal muscles, spastic gait and increased muscle tone caused by contraction of
gastrocnemius and anterior tibialis muscles. Sensation was intact throughout. Electromyography
demonstrated contraction of antagonistic muscles. Lumbar spine MRI indicated degenerative changes,
with no evidence of myelopathy or radiculopathy. Repeatedly, Quest Diagnostics found GADA level to be
over 30u/mL (maximum range) which was 20.7u/ml when she was diagnosed with SPS three years ago.
Quantifying autoantibody levels using specific radioligand assays and HLA genotyping were measured.
Her GADA index was strongly positive at 0.6 (99 th =0.05). HLA typing revealed DQB*0201/*0302
heterozygosity (DR 3/4) which is the genotype at greatest risk for type 1 diabetes. She had one 5-day
course of IVIG in hospital with temporarily improved symptoms, requiring management by a pain
specialist later.
DISCUSSION: SPS diagnosis is often made by exclusion and requires high index of suspicion and
treatment needs multiple specialists to collaborate. In this patient, symptoms persisted for 7 years
before she was first tested for GADA. Patients may benefit from sequential trials of other
immunotherapies. Psychiatric consultation may be helpful in managing the stress. The clinical
presentation and presence of both GADA and a very high risk HLA genotype favor the diagnosis of latent
autoimmune diabetes in adults (LADA), a subclass of type 1 diabetes. If the latter is indeed present, we
would expect serum C-peptides to decrease over time, along with an eventual requirement for insulin
therapy.
283

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Abdulghani Saadi, MD
Malignant peritoneal mesothelioma 37 years after intra-peritoneal radiotherapy with P-32.
Abdulghani Saadi, MD , Marwa Hegagi, MD , Haneen Aibak MD, Richard Williams, MD, FACP. Harbor
Hospital, Baltimore MD
INTRODUCTION: Malignant peritoneal mesothelioma (MPM) is an aggressive neoplasm that arises
from the lining mesothelial cells of the peritoneum and rapidly spreads within the confines of the
abdominal cavity. MPM is an understudied disease compared to the plural variant, although they share
the same predominant risk factor, asbestos exposure. Our patient had a different story.
Histopathology exhibited moderately differentiated malignant mesothelial cells with
immunohistochemical staining positive for calretinin,cytokeratin 5,6,EMA,thrombomodulin and negative
for Ber-EP4,ER,PR,all of which are compatible with moderate to poorly differentiated malignant
epitheliod mesothelioma.
CASE PRESENTATION: A 70 year old Caucasian woman presented with painless abdominal distention
for 3 weeks, without weight loss. She had a past medical history of ovarian cancer 37 years previously,
for which she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed
by intraperitoneal radioactive phosphorus 32 radiotherapy in the early 1970s. She managed to lead an
uneventful course for a solid 37 years after the treatment of her ovarian cancer. She was a nonsmoker,
nondrinker. She reported no exposure to asbestos. She had worked as seamstress in a mattress factory
for 20 years.
On examination, she was an average build female, anicteric, with no stigmata of chronic liver disease,
abdominal exam reveled ascites which was confirmed by ultrasound.
She was mildly anemic with hemoglobin of 9.8 and hematocrit of 28.7. She had a normal liver profile
and negative viral hepatitis screen. CA 125 was elevated at 299. Paracentesis revealed exudative ascites
with SAAG less than 1.1 and cytology showed atypical mesothelial cells.
Exploratory laporatomy reveled ascites with peritoneal and liver seeding.
P-32 is utilized in the treatment of peritoneal carcinomatosis. Patients who survive long term following
such treatment are at risk of MPM.
DISCUSSION: MPM is a very rare neoplasm. Asbestos exposure constitutes the major risk factor, just as
for the more common pleural MM. Other risk factors include papovirus, thorotrast exposure, radiation,
and chronic peritonitis. Our patient, however, had no history of asbestos exposure, and there was no
histopathologic evidence of ferruginous bodies. The long latency period between her exposure to a
potential carcinogen and the development of MM is typical and has been described in the literature on
several occasions but mostly relating to exposure to radiotherapy for lymphomas and characteristically
it has a very long latency of 2 to 3 decades.
284

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Sunita Sharma, MBBS
Knuckle, Knuckle, Dimple, Dimple
Sunita Sharma, MBBS Suma Singh, BA Luis Rivera-Ramirez, MD; Richard B. Williams, MD, FACP
INTRODUCTION: Pseudohypoparathyroidism (PHP) refers to a group of inherited disorders with various
clinical findings typical of hypoparathyroidism, often associated with skeletal and developmental
abnormalities. Unlike true hypoparathyroidism whose hypocalcemia is due to parathyroid hormone
(PTH) deficiency, in pseudohypoparathyroidism, hypocalcemia is associated to elevated parathyroid
hormone levels but a deficient target organ response to the PTH. We report the case of a patient
presenting with asymptomatic hypocalcemia, later found to have pseudohypoparathyroidism.
CASE PRESENTATION: A 22-year-old Caucasian male presented to the Endocrine clinic upon referral of
his primary care provider for asymptomatic hypocalcemia. He reported fatigue and cold intolerance, but
denied any changes in appetite or body weight. He had congenital hypothyroidism for which he was
taking 137 mcg of levothyroxine daily but no other medical problems. He denied tobacco, alcohol, or
illicit drug use. Physical examination showed a short-stature of 5-foot tall overweight male with a round
facies. His fourth and fifth metacarpal bones (knuckles) were shortened bilaterally, demonstrating
typical “Knuckle, Knuckle, Dimple, Dimple” appearance. There was no palpable thyroid gland. Laboratory
investigations showed normal CBC and liver panel, calcium 8.1 mg/dL, phosphate 5 mg/dL, and intact
PTH 496 pg/mL. 25-hydroxy Vitamin D level was within normal range. He was treated with oral vitamin D
and calcium. After 2-3 months of therapy, serum calcium, phosphate and PTH levels normalized.
DISCUSSION: Pseudohypoparathyroidism (PHP) can present in several ways, including asymptomatic
hypocalcemia, neonatal hypothyroidism, hypogonadism. There are various forms of PHP, namely type I
(i.e., Ia, Ib and Ic) and type II. PHP-I is the most common. PHP-I is transmitted in autosomal dominant
fashion and is due to mutations in the GNAS1 gene on chromosome 20q13. GNAS1 gene codes for the
stimulatory alpha-subunit of the trimeric Gs protein that connects G-protein coupled receptors of
various hormones (TSH, LH, FSH, PTH) with intracellular compounds for signalling cascades. Mutations in
GNAS1 gene lead to: (1) decreased sensitivity of tissues normally responsive to PTH causing
hypocalcemia and hyperphosphatemia; (2) decreased response to TSH leading to primary
hypothyroidism. These metabolic disturbances can present with a combination of clinical findings
including short stature, obesity, shortened fourth and fifth metacarpal bones due to premature closure
of the epiphyses, and round face, i.e. Albright’s Hereditary Osteodystrophy (AHO). AHO phenotype
presents in PHP subset Ia. Gene imprinting plays a role in its inheritance.The paternal GNAS1 gene is
paternally imprinted (silenced) in the renal cortex. Metabolic findings of PHP become present only in
patients who inherit a mutated allele from their mothers. It appears that our patient inherited a
mutated maternal allele for GNAS1 which explains his combination of metabolic abnormalities and AHO
phenotype (PHP type Ia).
285

MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Namita Singh, MD
A RARE CAUSE OF RHABDOMYOLYSIS: DULOXETINE
Namita Singh, MD; Rashmi Chandra, MBBS; Eric M Brown, MD
INTRODUCTION:Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) and is
approved by the FDA for the treatment and maintenance of major depressive disorder. It has also been
approved for the management of neuropathic pain associated with diabetic peripheral neuropathy,
generalized anxiety disorder, fibromyalgia, and chronic musculoskeletal pain. Although potentially lifethreatening
serotonin syndrome, depression/ suicidal ideation and hepatic failure have been wellpublished,
there have been only few cases of duloxetine-induced rhabdomyolysis reported so far.
CASE PRESENTATION: 63-year-old woman presented to the emergency room with altered mental
status for 2 days duration; nausea and diffuse muscle pains for a week. Past medical history included
hypertension, chronic obstructive pulmonary disorder, osteoporosis, chronic back pain, bipolar disorder
and Alprazolam-induced psychosis. Her long-term medications were temazepam, sertraline, oxycodone,
morphine, cyclobenzaprine, hydrochlorothiazide, irbesartan, metorpolol, Vitamin D and lansoprazole.
Only recent medication change was addition of Duloxetine (Cymbalta) 2 weeks ago. On presentation,
patient was tachycardic (PR 110/min), hypotensive (BP 66/38 mm Hg), easily arousable, however
remained confused. Rest of the examination was benign. Laboratory tests showed acute renal failure
(BUN 114mg/dL, Creatinine 13.6mg/dL with baseline 0.66mg/dL), and severe rhabdomyolysis (CPK
10,320 U/L, Myoglobin 4,503 mcg/ml). The patient was admitted to intensive care unit and was treated
with intravenous fluid resuscitation with bicarbonate-containing fluids. Psychiatry consult was requested
and as per recommendations, duloxetine was discontinued. Following the discotinuation of duloxetine,
her rhabdomyolysis and acute renal failure resolved over the subsequent several days. She improved
gradually with aggressive fluid hydration and was discharged home in stable condition on day 10.
DISCUSSION: The temporal fashion in which rhabdomyolysis and acute renal failure occurred within 2
weeks of starting new therapy with duloxetine, without any other changes in the health status/
medications, and improvement with discontinuation of the therapy, suggests duloxetine to be the
etiology in our patient. During literature review, the author came across four cases of rhabdomyolysis
caused by SNRIs (exclusive of serotonin syndrome). Duloxetine has been reported in two cases- one
described with co-ingestion of alcohol, and the other in the setting of recent addition of quetiapine. One
group has illustrated an interaction between citalopram and irinotecan leading to rhabdomyolysis. There
is also an article reviewing three cases of rhabdomyolysis due to SSRIs and eccentric exercise. Some
patient and physician groups have been reporting side-effects of duloxetine to FDA and several online
sites. An internet website ehealthme.com states that as on November 17, 2011, Rhabdomyolysis
constitutes 0.32% of the side-effects reported with Duloxetine. This information was based on 86
reports from FDA and user community.
The authors conclude that Duloxetine may cause severe rhabdomyolysis and clinicians should be aware
of this adverse event. There should be all attempts to minimize its occurrence and identify it in early
stages to prevent catastrophic consequences.
286

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Uday Chintamani
Lele, MD
The role of MTHFR 677TT genotype in a case of recurrent Thrombotic Thrombocytopenic Purpura
(TTP)
Uday C Lele, MD(Associate), Patricio Cabral, MD(Associate), Yutthapong Temtanakitpaisan,
MD(Associate), MetroWest Medical Center, Framingham, MA.
INTRODUCTION:Homozygous C677T mutation in the Methylentetrahydrofolate Reductase gene
(MTHFR 677TT genotype) is an inherited thrombophilic risk factor which has been implicated in
pathogenesis of multiple small-artery occlusions. Recent clinical studies suggest that the individuals
carrying this genetic variant are at an increased manifestation risk and are predisposed for a more
severe clinical course of TTP. We hereby report an intriguing case of a patient with MTHFR 677TT
genotype presenting with recurrent episodes of TTP.
CASE PRESENTATION: A 31 year old Hispanic woman presented to the Emergency Department (ED)
with complaints of acute onset of dizziness and garbled speech. Patient had a history of two previous
episodes of TTP associated with pregnancy which responded to multiple rounds of plasma exchange and
high dose steroids. Her latest episode was six months ago. The initial laboratory results from ED showed
a normal white blood cell count (9400/cu.mm), anemia (hematocrit 19.7%) and thrombocytopenia
(6000/cu.mm). Schistocytes were identified on peripheral blood smear. Renal and liver function tests
were normal. Serum Lactate dehydrogenase (LDH) level was elevated (1468 units/lit). Coagulation
profile and serum fibrinogen level were normal. Urine pregnancy test was negative. Computed
Tomography of brain revealed no evidence of acute infarct or bleeding. Relapse of TTP was recognized
and patient was treated with infusions of fresh frozen plasma and multiple rounds of plasma exchanges
resulting in significant improvement in blood counts. Additional workup showed ADAMTS13 activity of
less than 5% and presence of ADAMTS13 inhibitory antibody (1.6 Inhibitory Units) suggesting an
acquired TTP. Lupus anticoagulant, anti-dsDNA antibodies, as well as anti-phospholipid antibodies were
negative. Due to recurrent episodes of TTP, a screen for genetic polymorphisms associated with
thrombophilia was requested, which only disclosed MTHFR 677TT genotype status. Serum homocysteine
level was also noted to be elevated at 19.5 micromol/litre. She was treated with four cycles of rituximab
therapy prior to her discharge and was maintained on vitamin B complex therapy to avoid future TTP
relapse.
DISCUSSION: The exact pathomechanism that promotes microvascular thrombosis in presence of the
MTHFR 677TT genotype has not yet been fully established. It has been suggested that the MTHFR 677TT
genotype causes disruption of endothelial function by triggering the inflammatory response, by inducing
a hypercoagulable state, and by promoting endothelial activation which altogether can lead to
thrombosis of the arterial microvasculature. Therefore, in patients with recurrent episodes of TTP,
judicious management of MTHFR 677TT genotype status is imperative as it may help in reducing future
episodes of TTP by improving the overall endothelial function.
287

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Denisa Bellani, DO
A UNIQUE PRESENTATION OF SEPTIC THROMBOPHLEBITIS
Denisa Bellani, DO J. Grant MD, K Lwin MD, H.Aroke MD.
INTRODUCTION:This is a unique case presentation of septic thrombophlebitis in a young female with
no risk factors and a normal vaginal delivery.
CASE PRESENTATION: A 21 year old primigravid underwent normal vaginal delivery then on postpartum
day # 7 presented with high grade fever, chills and right lower quadrant pain. She had
intermittent fevers 104-107oF for two-three days prior to her emergency room visit. She denied nausea,
vomiting, or change in bowel habit. Her vitals were significant for Tmax 103, HR 143, BP 124/45 Sat 95%
on RA. The exam revealed an obese female in no apparent distress, with tachycardia, clear lungs and
abdominal exam showing a post-gravid abdomen, soft, non-tender and with bowel sounds present.
There was no rebound, rigidity and no costovertebral angle tenderness. Laboratory data was significant
for a white count 20.1, bandemia 15%, normal electrolytes, normal kidney function and mildly elevated
AST 33 U/L ALT 40 U/L and Alk Phos 197. CT of the abdomen demonstrated right gonadal vein
thrombosis with extension of the thrombosis into the inferior vena cava with prominent retroperitoneal
inflammation, mild ureteral dilatation secondary to adjacent inflammation, prominent postpartum
uterus and slight prominence of the right ovary. The patient diagnosed with sepsis was managed with
fluid resuscitation of 3L normal saline and initial placement on Ceftriaxone 2 g daily, Vancomycin 1 g IV
q12 hr, and Clindamycin 900 mg IV q8hr. Blood cultures revealed Fusobacterium 2/4 at which point the
patient was transitioned to Piperacillin-Tazobactam 3.375 mg IV q6hr. For the treatment of
thrombophlebitis patient was placed on Enoxaparin 90 mg SQ BID. Patient became afebrile and was
discharged with Augmentin 875 mg BID for a total of 28 day treatment along with Enoxaparin injections
for 6 weeks.
DISCUSSION: The overall incidence of septic pelvic thrombophlebitis is noted to be 1:3000 deliveries,
with 1:9000 after vaginal deliveries and 1:800 after cesarean section. Patients present within 7 days of
delivery with abdominal pain on the side of thrombophlebitis. Right ovarian vein is the most commonly
involved. Diagnostic criteria for septic thrombophlebitis include imaging studies: computed tomography
(CT) scan or ultrasound or immediate defervescence following heparin therapy. Fibronopeptide A (FPA)
is the first peptide cleaved from fibrinogen during thrombin mediated fibrin generation, levels greater
than 14 ng/ml could confirm septic thrombophlebitis when missing imaging confirmation. Management
involves ligation of both ovarian veins and inferior vena cava or heparin as an alternative effective
treatment with the addition of antibiotics.
288

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Anju Bhagavan, MD
Frozen Blue Toes
Anju Bhagavan, MD Vasanth Kainkaryam MD, Yee Chuan Ang MD
INTRODUCTION:Cryoglubulinemia is the occasional presence of abnormal serum proteins in patients
with autoimmune diseases, multiple myeloma, leukemia or certain forms of pneumonia, which result in
hyperviscosity and tissue necrosis, potentially leading to limb amputation without early intervention.
CASE PRESENTATION: 62 year old female with a history of hypertension and fibromyalgia presented to
our tertiary care center for acutely worsening pain in her right foot after failed outpatient analgesic
management. She reported constant pain, associated with a bluish discoloration of toes and swelling of
all digits. She had noticed a similar discoloration a year ago, exacerbated by cold temperatures.
Extensive rheumatological workup was unremarkable, and trials of prednisone and nifedipine, though
with initial relief, were not successful. She was admitted for pain control and limb evaluation for
gangrene. On presentation, except for mild tachycardia, she was hemodynamically stable. She was
found to have a cyanotic discoloration of her right toes with significant swelling of her second and fifth
toes. There was coolness to touch along with pain to palpation. Her left foot was within normal limits.
Good peripheral pulses were appreciated and sensation was intact. In addition, all of her fingers were
swollen and tender. Livedo reticularis was present on both lower extremities.
Initial labs were significant for leukocytosis 19.7 k/mm3, ESR 52 mm/hr, CRP 9.9 mg/dl, AST 239 units/L,
ALT 374 units/L. The Vascular Surgeons were concerned for atherosclerotic emboli resulting in “blue toe
syndrome,” for which the patient was started on aspirin and a statin. However, the leukocytosis, hand
swelling, and rash could not be explained. Her Rheumatologist was consulted, and was concerned for a
rheumatoid vasculitis, so repeat rheumatological workup was obtained.
She continued to have pain in her right foot with worsening gangrene. Cryoglobulin level was positive
with IgG kappa M spike on immunofixation. Total IgG, IgA and IgM levels were low. Hepatitis C antibody
was negative. She was diagnosed with Type 1 cryoglobulinemia with IgG kappa protein, and was started
on IV cyclophosphamide, bortezomib and dexamethasone with improvement of the rash and swelling.
She did, however, require eventual amputation of her right 2nd, 4th and 5th toes due to gangrene.
DISCUSSION: Cryoglobulinemia is the presence of cryoglobulins (immunoglobulins that undergo
precipitation at low temperatures) in the serum, causing systemic inflammation affecting the skin and
joints. Three types of cryoglobulinemia have been identified. Type 1 does not have rheumatoid factor
activity and is usually associated with lymphoma, Waldenstorm’s macroglobulinemia and multiple
myeloma. Treatment depends on the type, severity of symptoms and degree of hyperviscosity. It usually
responds to chemotherapy and plasmapharesis. Quick diagnosis and treatment are necessary to prevent
limb ischemia or loss.
289

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Shihab Masrur
Paraneoplastic Hyperthyroidism In A Patient With Extragonadal Germ Cell Tumor.
Shihab Masrur, Jaime Solorzano, Quret-ul Quresh, Ning Fu, Sukhpal Mann
INTRODUCTION: Familiarize with rare paraneoplastic hyperthyroidism associated with extragonadal
germ cell tumor and its treatment. Extragonadal germ cell tumors (EGGCT) represent about 5% of all
germ cell tumors. EGGCT syndromes are rare tumors that predominantly affect young males. Human
Chorionic Gonadotropin (HCG) induced hyperthyroidism represents a rare paraneoplastic syndrome in
HCG-secreting germ cell tumors. We report a case of young male patient with EGGCT and paraneoplastic
hyperthyroidism.
CASE PRESENTATION: A 46-year-old man was recently diagnosed with mixed EGGCT after extensive
outpatient work up and a retroperitoneal biopsy presented with cough, dyspnea and progressive
fatigue. Patient was treated symptomatically for respiratory failure due to pulmonary metastasis.
Patient started to show improvement in two days but he was noticed to be increasingly fatigued and
remained tachycardic. Physical exam revealed a pulse rate 116 per minute and respiratory rate 22 per
minute with mild tremors without any other signs of hyperthyroidism. Lab data showed an elevated T4:
4.0, low TSH: 0.01, very high LDH: 1422 and HCG: 281,267. He was successfully treated with Cisplatin
based chemotherapy with normalization of his T4 and HCG: 3374.
DISCUSSION: Incidence of paraneoplastic hyperthyroidism in extragonadal GCT is unknown. The
incidence of hyperthyroidism in testicular germ cell tumor is 3.5%. The most accepted explanation of
hyperthyroidism is the weak TSH-like activity of HCG. In the absence of clinical signs of hyperthyroidism,
treatment usually consists of specific chemotherapy directed toward tumor resulting in normalization of
thyroid function if HCG declines. Cisplatin based chemotherapy including etoposide, ifosfamide are used
for treatment. The symptoms of hyperthyroidism also abate with return of HCG levels to normal.
Overlapping thyrostatic treatment has also been recommended. Patients with elevated tumor
biomarkers like HCG or metastatic disease have poor prognosis however with chemotherapy 5-year
survival rates is about 50%. High-dose chemotherapy followed by autologous peripheral stem cell or
autologous bone marrow support has also been investigated.
CONCLUSION: Although rare, paraneoplastic hyperthyroid syndrome in EGGCT should be recognized
for successful chemotherapy treatment. Further studies are warranted for incidence and prognosis.
290

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Vinod Mohan, MD
Abiotrophia Defectiva: Should the Valve Come Out?
Vinod Mohan, MD, Sirin Pandey, MD (Associate), Shilpi Mittal, MD (Associate) Akhila Belur, MD, Alwyn
Rapose, MD Departments of Medicine, St. Vincent Hospital and the Reliant Medical Group, Worcester,
MA
INTRODUCTION: Abiotrophia defectiva is a part of normal oral flora. Endocarditis due to Abiotrophia
species is a rare entity. It is often associated with negative blood cultures. Treatment failures
and infection relapses are higher than in endocarditis caused by other viridians streptococci. Even
though antibiotic guidelines are laid down, abiotrophia defectiva endocarditis is associated with high
morbidity and mortality.
CASE PRESENTATION: The patient is a 54-year-old lady admitted with left upper quadrant pain. A CT
scan showed a splenic infarct. Trans-thoracic echocardiography showed a moderate sized aortic
vegetation with aortic regurgitation. A transesophageal echocardiogram confirmed the vegetation.
Blood cultures grew Abiotrophia defectiva in four out of four bottles. The patient was started on
penicillin and gentamicin, but, unfortunately, developed gentamicin induced acute renal injury. Since
she did not satisfy the criteria for aortic valve replacement, surgery was deferred. Based on the
sensitivity profile, treatment was switched to ceftriaxone. She completed 6 weeks of antibiotic therapy,
but five months later returned with severe aortic insufficiency and systolic heart failure, with a drop in
ejection fraction from 55% to 30%. Aortic valve replacement was undertaken. Valve microscopy showed
gram positive cocci. The organism seen in the Gram stain was not recovered by culture. It is suspected
that organism lost viability. After the surgery the patient’s cardiac function improved, and she
completed another six weeks of ceftriaxone.
DISCUSSION: Abiotrophia defectiva, previously referred to as nutritionally variant streptococci, is a rare
and fastidious organism which is very resistant to antibiotics. Nutritionally variant streptococci species
have shown great tolerance to penicillin. Our case demonstrates the scenario where the patient
required valve replacement in spite of in-vitro sensitivity to ceftriaxone. The experience from this case
as well as others in literature strongly suggests the need for early surgical intervention when
Abiotrophia defectiva endocarditis is encountered. Even though current case do not completely indicate
treatment failure , it adds to the literature about treatment difficulty in abiotrophia defectiva
endocarditis. It also shows the need for more organism specific surgical guidelines for endocarditis
management.
291

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Owolabi Ogunneye,
MD, MRCP
Posterior Reversible Encephalopathy Syndrome Associated With Para-influenza Virus Infection. Under So
Much Pressure!
Owolabi Ogunneye, MD, MRCP. Jaime Hernandez, MD James Canoy, MD Daniel Landry, DO
INTRODUCTION: Posterior reversible encephalopathy syndrome is a clinicoradiological entity first
described by Hinchey in 1996. The common clinical features are headache, seizures, visual changes and
altered mental status. MRI allows more precise characterization and recognition of PRES than CT(1).
CASE PRESENTATION: A 54year-old Caucasian female presented with uncontrolled hypertension and
new-onset seizures. Five days before presentation, she developed generalized headache and blurring of
vision and she visited her closest ED, which found her hypertensive with a SBP of 260 mmHg. She was
treated with analgesics and parenteral antihypertensive medications with partial improvement of
symptoms and was subsequently discharged to her home in rural Western Massachusetts. 24 hours
before admission, she again visited her local ED complaining of similar symptoms. Blood pressure
recorded at the time was 260/160 mmHg. She was again treated with IV narcotics and
antihypertensives, however while being treated she developed confusion and the decision was made to
transfer the patient to our hospital. On route she had an episode of tonic-clonic seizure activity lasting 3-
4 minutes. Her medical history was notable for hypertension, SLE, ESRD on peritoneal dialysis. Her
initial laboratory data was relevant for leucocytosis of 16,500. She underwent CT scan of the brain and
LP for CSF analysis which was unremarkable. Empiric treatment for viral and bacterial meningitis with IV
acyclovir, vancomycin and ceftriaxone followed. Blood and CSF cultures were unremarkable. On ICU day
2, the patient developed a fever of 102.0 F and a nasopharyngeal direct fluorescent antigen test was
positive for Para-influenza virus confirmed with viral cultures for Para-influenza Type 3. Lupus activity
studies showed normal C3/C4 levels, elevated Complement 50 levels >60. An MRI of the brain without
contrast was performed on ICU day 2 revealing changes in the posterior hemispheres.
DISCUSSION: A case has been reported of an association between influenza A virus and PRES(2). Our
case is unique in that Para-influenza virus infection has not been reported in the literature as an
association with development of PRES. Our patient was treated symptomatically, with particular
attention given to aggressive blood pressure control. She recovered fully with no residual neurological
deficit. We postulate that our patient experienced an episode of coexistent hypertensive-SLE and
infection-associated PRES precipitated by a combination of uncontrolled hypertension and Parainfluenza
virus type 3 infection. Both associations favor the contribution of endothelial dysfunction.
Reference
1- Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. J Intensive care Med:2011
Feb, 23.
2- Bartynski WS, Upadhyaya AR, Boardman JF. Posterior reversible encephalopathy syndrome and
cerebral vasculopathy associated with influenza A infection: Report of a case and review of the
literature. J Comput Assist Tomogr:2009; 33(6): 917-22.
292

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Owolabi Ogunneye,
MD, MRCP
A Rare Case Of Cerebellar Abscess Secondary To Peptostreptococcus Sp. from An Odontogenic Source.
The Way To A Man’s Brain!
Owolabi Ogunneye, MD, MRCP Eric Churchill, MD, MPH.
INTRODUCTION: Cerebellar abscesses account for 9-28% of all brain abscesses and 85-99% of cases
result from contiguous spread of infection from an ipsilateral ear or sinus source (1). Advances in
neuroimaging techniques as well as the introduction of more effective antibiotics have reduced the
mortality of brain abscesses to 0-24% (2).
CASE PRESENTATION: An immunocompetent 41year old Caucasian female was admitted with 2week
history of neck pain/stiffness associated with occipital headache radiating to the frontal region. Five
days prior to admission, she presented to the ER of this facility with worsening symptoms and was
discharged to her home in rural western Massachusetts after Brain CT and lumbar puncture were
unremarkable. On the day of admission, she developed diplopia while driving, associated with
intractable nausea and vomiting. She smokes 1 pack cigarettes/day and drinks alcoholic beverages
socially. Physical examination revealed a febrile patient, temperature (39 C). Intraoral clinical and
panorex imaging revealed the presence of generalised periodontal disease, multiple dental caries and
loose teeth. Cardiac, Respiratory and Integumentary system examinations were unremarkable.
Neurological examination revealed an awake, alert and oriented patient with no focal weakness.
An MRI of the brain with contrast at the time of admission revealed a left cerebellum abscess and a
small left cavernous sinus abscess with septic thrombophlebitis. She was empirically started on
vancomycin (1gm IV 8qhrs) and ceftriaxone(2gm IV q24hrs) pending results of blood cultures and the
dentist was consulted for extraction of decaying teeth. Two days after admission, she became
unresponsive prompting an ICU transfer. Head CT revealed obstructive hydrocephalus. A right frontal
external ventricular drain was placed for decompression. CSF studies showed elevated protein, with low
glucose. A set of two blood cultures drawn on admission returned positive for Peptostreptococcus Spp.
The patient was discharged after 2weeks inpatient care. She received a 12-week course of antibiotic
therapy. All her symptoms resolved completely. She remained asymptomatic with no residual deficit.
DISCUSSION: This case is unique due to the location of the abscesses, the patient’s immune status and
the possible odontogenic source of the infection. Dental pathogens from oral infection could enter the
brain through either through a hematological route (facial, angular, ophthalmic artery, spread through
the cavernous sinus as in our patient) (2). Given our patient’s generalized periodontal disease, positive
blood culture for an oral pathogen “Peptostreptococcus”, cavernous sinus abscess and the lack of an
alternative source of infection, we postulate that her cerebellar abscess arose via spread through the
left cavernous sinus.
References
1- Richard,A Martinello, Elizabeth,L.Cooney. Cerebellar brain abscess associated
with tongue piercing. Clinical infectious disease. 2003;36:e 32-4.
2- Anastossios I. Mylonas et al. Cerebral abscess of odontogenic origin. Journal of craniomaxillofacial surgery.2007:35;63-67.
293

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Atul Vijay Palkar,
MD
Statin Interactions: Do we know enough?
Atul Vijay Palkar, MD* (Associate) Lily Wong** (MS IV), Robert Black, MD*** *Department of Internal
Medicine, Saint Vincent Hospital. **University of Massachusetts Medical School. ***Professor of
Nephrology, Saint Vincent Hospital
INTRODUCTION: Rhabdomyolysis is a potentially life-threatening condition which can result in acute
kidney injury (AKI). Several hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins)
have been associated with a rise in creatine phosphokinase (CPK). Rhabdomyolysis leading to AKI is less
common. We report a case of severe muscle injury resulting in AKI that occurred as a result of a
simvastatin-antibiotic interaction.
CASE PRESENTATION: A 69 year old gentleman was seen by his primary care physician for epigastric
discomfort and was diagnosed with Helicobacter pylori gastritis. Since 2006, he had been on simvastatin
80 mg daily, ezetimibe 10 mg once daily and gemfibrozil 600 mg twice daily for hyperlipidemia. He was
started on triple therapy with amoxicillin, lansoprazole and clarithromycin. One week later, he
developed extreme fatigue and muscle aches. He also complained of muscle weakness, which
progressed to the point where he required assistance with ambulation. His past medical history was
significant for chronic kidney disease (stage III, estimated glomerular filtration rate 52.6 ml/min),
coronary artery disease, hypertension, and hyperlipidemia. Physical examination was remarkable for
proximal muscle weakness and tenderness. Blood urea nitrogen was 100 mg/dL, serum creatinine 2.72
mg/dL, CPK 17364 U/L. His urine was positive for myoglobin and his urine sediment showed many
granular casts but few red cells. His peak serum creatinine was 2.72 mg/dL and his peak CPK was 17525
U/L. With the discontinuation of clarithromycin, simvastatin and gemfibrozil and with supportive care,
his muscle enzymes and renal function gradually improved.
DISCUSSION: Clarithromycin is known to be a potent inhibitor of CYP3A4, the major enzyme
responsible for simvastatin metabolism. Gemfibrozil is an organic anion-transporting polypeptide (OATP)
1B1 inhibitor, which interferes with the hepatocyte uptake of simvastatin, and also interferes with statin
glucuronidation, a step necessary for statin elimination. These drugs, when combined with a maximal
dose of simvastatin (80 mg/day), resulted in a rise in statin levels and the risk of muscle injury. By
comparison, rosuvastatin, pitavastatin, and pravastatin have minimal hepatic metabolism and
fluvastatin is metabolized by CYP2C9; hence they are less susceptible than atorvastatin, lovastatin, and
simvastatin to CYP3A4 interactions.
Our observations confirm that high dose simvastatin should be used with caution given its risk of causing
rhabdomyolysis, particularly in combination with CYP3A4 inhibitors and gemfibrozil. Alternate therapy
with rosuvastatin, pitavastatin, or pravastatin, lowering the statin dose, or temporary discontinuation of
the statin should be considered in this setting.
294

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Srijana Ranjit, MD
Treatment of AA Amyloidosis in Psoriatic Arthritis with Etanercept
; Srijana Ranjit, MD (Associate), William Gaines, MD, Robert Yood, MD, FACP Departments of Medicine,
St. Vincent Hospital and the Reliant Medical GroupFallon Clinic, Worcester, MA
INTRODUCTION:Secondary AA amyloidosis (SAA) is an uncommon complication of chronic
inflammatory diseases, including inflammatory arthritis. We present a patient with amyloidosis
secondary to poorly controlled psoriatic arthritis who responded to treatment with a tumor necrosis
factor (TNF) inhibitor (etanercept).
CASE PRESENTATION: A 67 year-old man with a past medical history of hypertension, hyperlipidemia,
and hypothyroidism was diagnosed with polyarticular psoriatic arthritis over 25 years ago. His arthritis
was poorly controlled despite various treatments, including intramuscular gold, sulfasalazine, and
methotrexate. The patient self-treated with multiple complementary and alternative medications. Anti-
TNF treatment was considered in 2003 but not given because at that time the patient was undergoing
treatment for metastatic small cell lung cancer. He was maintained on low dose prednisone with poor
control of his arthritis.
In November 2004, about 20 years after the onset of arthritis, routine urinalysis documented
proteinuria; urinalysis 6 months earlier was normal. His renal function deteriorated with serum
creatinine increasing to 1.6 mg/dL. A random urine protein creatinine ratio was 7.8. An abdominal fat
pad aspirate was negative for amyloid, but a renal biopsy with immunofluorescence microscopy in April
2005 documented AA amyloidosis. Etanercept was started June 2005 with dramatic improvement of his
psoriasis, synovitis, and renal disease within 6 weeks. His urinary protein creatinine ratio decreased to
2.0. His sedimentation rate decreased from 126 mm/hr prior to etanercept therapy to 69 one year later
and 23 after 2 years of treatment. Etanercept was continued and in June 2011 his serum creatinine was
1.01 mg/dL and random urine protein creatinine ratio 0.6.
DISCUSSION: Although there are studies showing use of TNF inhibitors to treat AA amyloidosis
secondary to rheumatoid arthritis, there is little information on the use of these drugs in the treatment
of AA amyloidosis secondary to psoriatic arthritis. Treatment of AA amyloidosis secondary to
rheumatoid arthritis has led to rapid improvement of proteinuria and stabilization of renal function. The
improvement in renal function is likely secondary to suppression of inflammation which triggers SAA.
Our patient had a dramatic response to etanercept with marked improvement in his psoriasis, resolution
of his synovitis, normalization of his serum creatinine and near-resolution of his proteinuria. He
continues etanercept with stable renal function after more than 6 years and demonstrates that
etanercept is a promising treatment of AA amyloidosis secondary to psoriatic arthritis.
295

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Renee K Rutledge,
MD
Steroid-resistant Asthma Exacerbation And A Paroxysmal Cough
Renee K Rutledge, MD
INTRODUCTION:The clinical disease known as pertussis was first described over 400 years
ago. Historically and epidemiologically an important disease, the number of cases dwindled in the late
20 th century due to widespread use of whole cell vaccines against the causative agent, Bordetella
pertussis. Paradoxically, this success has led to waning immunity in adults coupled with a major
resurgence, exemplified by the 2010 California outbreak of 9,143 cases -- the largest since 1947.
CASE PRESENTATION: A 64 year-old man with past medical history of previously well-controlled adultonset
asthma presented for the third time reporting dyspnea, wheezing, and cough. On initial
presentation he reported two weeks of cough productive of clear to yellow sputum, with two days of
wheezing and nocturnal dyspnea. He denied fevers, chills, rhinorrhea, sore throat, or sinus congestion.
Chest radiograph excluded infiltrates, so he was treated with albuterol/ipratropium nebulizer, IV
methylprednisolone and discharged on prednisone taper. Three days later he re-presented with a dry
cough occurring in “fits,” despite corticosteroids and inhaler, and then presented for a third time with
persistent coughing fits that were interrupting sleeping and eating (though without post-tussive
emesis). He received two albuterol/ipratropium nebulizer treatments in the Emergency Department
that provoked atrial flutter and prompted hospital admission. On admission he was afebrile,
normotensive, and in atrial flutter with variable block with a heart rate of 80 beats per minute. Lung
exam revealed significant wheezing, comfortable breathing at a rate of 16, and oxygen saturation >95%
on room air. Shortly after arrival an explosive coughing fit was witnessed during which he became
diaphoretic, developed facial erythema and manifested a marked inspiratory whoop. The patient denied
ever having received a Tdap shot or any tetanus immunization in the past decade. Droplet precautions
were initiated, empiric azithromycin started, posterior nasopharyngeal swab obtained for Bordetella
pertussis, and serology sent to the state laboratory. The patient converted to normal sinus rhythm after
administration of diltiazem, and cough and overall respiratory status improved over three days.
Approximately one week post discharge, the Massachusetts State Laboratory confirmed positive
pertussis serology. In the absence of Tdap vaccination in the prior three years, this result is reported as a
positive case of pertussis in Massachusetts.
DISCUSSION: While a significant number of adult patients with cough greater than 7 days test positive
for pertussis in studies, few manifest the classic whoop. In addition, this case emphasizes the need to
continually re-evaluate diagnoses and treatment plans: multiple presentations for the same complaint
should always prompt internists to reconsider their differential diagnoses and previously disregarded
clinical clues. Fortuitously, in this case, atrial flutter prompted admission and provided physicians the
opportunity to witness the classic pertussis whoop, establishing the diagnosis of this persistent cough.
Note: Patient consented for video recording of a whooping episode, which the author has in electronic
format.
296

MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Praveen Sudhindra,
MBBS
An Unusual Case of a Cyclic Skin Rash
Praveen Sudhindra, MBBS George Abraham, MD, MPH Jennifer Sargent, DO
INTRODUCTION: Recurring rashes have many etiologies and may pose a management challenge. We
report a patient who presented with chronic, recurrent rash of a very unusual cause.
CASE PRESENTATION: A 41 year old female with a history of poorly controlled diabetes mellitus
presented with 3 days of fever and chills, along with redness, pain and discharge involving her left
breast. Initial physical examination was significant for erythema and serous discharge from the skin over
her left breast, along with tender left axillary lymphadenopathy. She was admitted for treatment of
presumed cellulitis with IV daptomycin. Over the next couple of days she developed a diffuse,
erythematous and pruritic rash with vesicles and urticarial plaques involving the trunk, arms and legs.
A diagnosis of dishydrotic eczema was made to explain the new rash. She was discharged home on
tapering doses of steroids and IV daptomycin for what was thought to be cellulitis secondary to chronic
eczema.
She was seen in follow up at the infectious disease clinic ten days following discharge. Upon
further investigation of the rash history we found a cyclical, self limiting pattern of her rash since she
was 14 years old. The rash usually recurred a few days prior to menses and would subside a couple of
days afterward. Furthermore, the rash developed during her hospitalization was consistent with her
usual pattern. She had undergone skin biopsies in the past which were inconclusive. She was treated
with steroid tapers on multiple occasions with temporary relief.
Given the cyclical nature of the rash, the possibility of Autoimmune Progesterone Dermatitis (AIPD) was
considered, and the patient was tested with a challenge of 0.1ml of intradermal medroxyprogesterone.
There was an immediate wheal response to the injection with subsequent induration 72 hours later. She
was started on oral contraceptives with an aim to reduce exposure to progesterone by suppressing her
ovulation cycle. She has remained symptom free for seven months, with only one flare since starting
treatment.
DISCUSSION: AIPD is a rare condition which requires the following diagnostic components: a) A history
of a perimenstrual cyclic rash; b) Immediate and/or delayed hypersensitivity response to intradermal
progesterone; c) Resolution of the rash by inhibiting ovulation.
Should the patient have recurrent flares on oral contraceptives, the next line of treatment involves
GnRH analogues, and ultimately, oopherectomy.
Currently there are about 60-70 reported cases of AIPD in the literature. Internists should be mindful of
the fact that recurrent perimenstrual rashes might be secondary to progesterone dermatitis, and
inhibiting the hypothalamic-pituitary-ovarian cycle may cure patients of the disease.
297

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Cristina T De Castro-Dela
Cruz, MD
What's In A Rash?: Follicular Non-Hodgkins Lymphoma Presenting as Paraneoplastic Pemphigus
Cristina T De Castro-Dela Cruz, MD
INTRODUCTION: Paraneoplastic pemphigus is a rare autoimmune blistering mucocutaneous disease
that is frequently associated with malignancy, especially lymphoreticular cancer.
CASE PRESENTATION: A 63 year old man was admitted with a progressive blistering rash after a skin
biopsy was read as erytheme multiforme. He reported a one-month history of oral lesions followed by
blistering skin lesions which started after initiation of medications for lower extremity edema. He also
experienced dysphagia and a 20- pound weight loss. He was evaluated by a dermatologist, and a skin
biopsy was done after which he was started on oral prednisone. Despite this, his lesions had continued
to progress and thus he was admitted.
Except for a slight lymphopenia, blood count and metabolic profile was normal. Because of the concern
for Stevens Johnsons Syndrome he was evaluated by an allergist and started on high dose intravenous
immunoglobulin. Despite treatment, his vesicobullous eruptions evolved and and covered more of his
body surface. He developed fevers up to 39°C and there was concern that infection was contributing to
his illness. The infectious disease service was consulted. Although no source of infection was identified,
Gentamicin was started. He developed respiratory insufficiency, chest roentgen revealed a pleural
effusion. Computerized tomography showed a moderate pleural effusion, ascites in the upper
abdomen, and an extensive soft tissue mass near the pancreas, central mesentery and retroperitoneum,
with diffuse adenopathy, concerning for lymphoma. CT scan of the abdomen and pelvis was performed,
showing a 10cm x 17cm confluent nodal mass within the root of the small mesentery. Tissue biopsy
confirmed the diagnosis of low-grade follicular lymphoma. A blood sample was sent for anti-desmoglein
antibodies 1 & 3 titers, which came back positive. His skin lesions were attributed to paraneoplastic
pemphigus. Estimated area of skin involvement exceeded 90% of body surface area.
He was started on Rituximab but developed a hypotensive infusion reaction necessitating transfer to the
medical intensive care unit. Plasmapheresis was initiated and he was given cyclophosphamide,
vincristine and prednisone. The patient continued to deteriorate, developed Pseudomonas skin
infection, and he needed to be intubated for respiratory failure with associated hospital acquired
aspiration pneumonia. The patient expired a few days later.
DISCUSSION: We report a case of paraneoplastic pemphigus, which presented as the first sign of
follicular lymphoma. The possibility of PNP should be considered when a patient presents with
significant oral ulcers and diffuse blistering regardless of a known malignancy. The diagnosis is
established with measurement of anti-plakin or anti-desmoglein auto antibody titers, skin biopsy with a
histopathology and immunofluorescence. Treatment with corticosteroids is first line but there are
newer modalities including rituximab and plasmapheresis. Thus far despite novel treatments the
mortality rate of paraneoplastic pemphigus is still very high.
298

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Mershed Alsamara, MD
Takotsubo Cardiomyopathy (Sad Heart) Secondary to Atrial Fibrillation Cardioversion
Mershed Alsamara, MD Yazan Khouri, MD. Reema Hasan, MD. Shukri David, MD
INTRODUCTION: Study:
This is a case of a patient presented with Takotsubo Cardiomyopathy few days after electrical
cardioversion for atrial fibrillation
Objective:
This case presents another trigger for Takotsubo which is a electrical cardioversion.
Literature talks about precipitants like emotional and physical stressors; including death, trauma,
surprising event, cocaine use and stress test. There is no case reported about Takostusbo as a result of
atrial fibrillation.
Cardiomyopathy after cardioversion with normal coronary arteries was suggestive of induced
dysfunction of the heart muscle.
CASE PRESENTATION: Case DISCUSSION: 81 Y/O African American Female presented to ER
complaining of new onset of shortness of breath, started the same morning, no chest pain, no nausea or
diaphoresis.
Patient was discharged from the hospital the day before after getting an electrical cardio-version of
atrial fibrillation.
In the ER patient was hypoxic, Chest X- ray was ordered showing pulmonary edema. ECG was done
showing ST elevation, cardiac enzymes came back positive; 2D echo showing severe systolic impairment,
akinesis in the intra ventricular septum, anterior wall, apex, mid and inferior wall, EF 20%. An old echo
from 2 months was available which showed normal LV with EF 60% and mild right atrial enlargement.
Patient was taken for left heart catheterization which showed non significant coronary arteries disease
with severely impaired LV systolic function, ballooning of the anterior wall consistent with (Tokotsubo).
Patient was treated with BB, ACE, CCB and diuresis.
Patient got another Echo before discharge which is showed improved LV contractility and EF of 30%.
DISCUSSION: This case presents Takotsubo cardiomyopathy after electrical cardioversion of atrial
fibrillation. This patient fits the picture of Takotsubo; cardiomyopathy after a stressful medical
intervention. No case reports exist in the literature about Takotsubo after cardioversion
299

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE In Chul An, DO
Coagulopathy from dabigatran in patient with ESRD - Should INR monitoring be totally neglected with
dabigatran?
In Chul An, DO Second Author: Abrar Sayeed, MD Third Author: Heather S. Laird-Fick, MD,MPH,FACP
INTRODUCTION: Dabigatran is an oral direct thrombin inhibitor which has been approved for
prophylaxis of stroke in patients with atrial fibrillation. Excitement over the drug is driven by two major
benefits. First, it is more effective than warfarin, without an increased bleeding risk. Second, its
normally predictable pharmacokinetics obviate the need for INR monitoring and dose
adjustment. Some patients may have altered pharmacokinetics, however, thereby altering the riskbenefit
ration of treatment. We present such a case.
CASE PRESENTATION: A 58 year old Caucasian male with history of recurrent paroxysmal atrial
fibrillation status post pacemaker and end-stage renal disease on hemodialysis came to the Emergency
Department with complaints of nose bleed. He was started on dabigatran 150 mg twice a day about 4
months ago as an outpatient by his cardiologist. He has had frequent nosebleeds for two months. The
day of presentation, the patient awoke to find himself in a pool of blood. His international normalized
ration(INR) was 8.8 and activated partial thromboplastin time(aPTT) 105.7, otherwise all labs were
unremarkable including liver function test. He did not miss any of his hemodialysis sessions.
DISCUSSION: Dabigatran is contraindicated in patients with severe kidney insufficiency as it is
predominantly excreted via the kidney (~80%). A reduced dose (75mg twice a day) is recommended for
patients with mild to moderate kidney insufficiency (GFR 30-60). As dabigatran directly inhibits prothrombin
to thrombin conversion, both intrinsic and extrinsic coagulation pathways are involved and
can contribute to coagulopathy. Despite the studies showing only mild increase of aPTT and PT/INR with
patients receiving dabigatran, closer monitoring may be reasonable in patients with renal insufficiency
as pharmacokinetics may be less predictable.
Despite predictable pharmacokinetics with dabigatran, it should be avoided in patients with severe
kidney insufficiency. Decreased renal clearance can cause coagulopathy and significant bleeding. More
studies are warranted looking at relationship of renal impairment and coagulation assays.
300

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Subramanyeswara Rao
Arekapudi, MD
Elevated Factor VIII: A Significant Risk Factor For Venous And Arterial Thromboembolism
Subramanyeswara Rao Arekapudi, MD, MPH, Associate Mudasser Saiyed Javed, MD Zuhair Aejaz, MD
Geetha Krishnamoorthy, M.D, Member. Department of Internal Medicine, Sinai-Grace Hospital/DMC.
INTRODUCTION:Elevated Factor VIII is considered as a risk factor for developing venous and arterial
thromboembolic events. Screening for factor VIII in a patient with arterial or venous thromboembolism
is not a common practice.
CASE PRESENTATION: A sixty two year old African American female was brought to the ED after she
collapsed. She was found out to be in pulseless electrical activity, resuscitated and admitted to the
intensive care unit. CT scan showed bilateral pulmonary emboli. She was started on heparin drip.
Bilateral lower extremity duplex was negative for deep venous thrombosis. Hypercoagulable work up
including protein C, protein S, anti thrombin, anticardiolipin antibody, lupus anticoagulant, factor V
Leiden and factor VIII were obtained during her prolonged hospital stay. Factor VIII alone was found out
to be elevated at 319.3% (normal 50-150%). Patient later gave history of 5 prior episodes of venous
thromboembolism, and had been on 6-12 months of warfarin each time. Many first degree relatives
were on warfarin. Patient was eventually discharged on warfarin with recommendations to continue it
lifelong. In the following few months, we have encountered two more African American women who
presented with pulmonary embolisms were found out to have isolated factor VIII elevation.
DISCUSSION: Elevated factor VIII level (>150%) is now well documented to be one of the
hypercoagulable states. There is a dose response relationship between the level of factor VIII and risk of
venous thromboembolism. It is associated with both venous and arterial thromboembolism. High body
mass index, high blood glucose levels, elevated vWF levels and Non O blood group might affect factor
VIII levels. First degree relatives of an affected individual are at high risk of developing venous
thromboembolism. Risk level varies in different races, and women are at higher risk. The genetic
determinants of elevated factor VIII are not yet identified. The intensity and duration of therapy with
warfarin has not yet been definitely determined, and it is also unknown whether first degree relatives
have to be screened. Importance of borderline elevation of factor VIII in acute settings is still debatable.
Conclusion: Isolated factor VIII elevation is a significant risk factor for developing recurrent
thromboembolic events resulting in severe consequences. Potentiality of factor VIII might be
undermined. Importance of including factor VIII activity in hypercoagulable work-up needs to be
established. Patients with venous thromboembolism and elevated factor VIII levels may need long-term
anticoagulation. Further research in understanding the potentiality of factor VIII is indicated.
301

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Amal Ashraf, MD
Spontaneous Splenic Rupture from Undiagnosed Histoplasmosis
Amal Ashraf, MD Second Author: Mimi Emig, MD, FACP
INTRODUCTION:Histoplasmosis is the most prevalent endemic mycosis in the US. Dissemination to the
reticuloendothelial system can occur, particularly in immunocompromised hosts. Dissemination has
been reported with the use of biologic chemotherapeutic agents, but not with standard
chemotherapy. In the spleen, Histoplasma can cause enlargement as well as infarcts. Atraumatic
splenic rupture from Histoplasma is highly unusual. We describe a case of unsuspected disseminated
histoplasmosis with an uncommon and potentially fatal presentation
CASE PRESENTATION: A 43 year old man presented with 2 months of chest pain. CT chest showed an
8cm upper lobe mass with chest wall invasion. Percutaneous biopsy demonstrated non-small cell lung
cancer with angiolymphatic invasion. PET CT demonstrated avid FDG uptake in the lung mass, without
abnormal uptake at any other site. The patient was started on taxol / carboplatin, but had increased
size of the lung mass after 2 cycles. He complained of fatigue, night sweats, and weight loss, which were
attributed to his lung cancer and chemotherapy. He underwent resection of the lung mass and involved
chest wall 2 ½ months after his initial diagnosis. Pathology showed large cell lung cancer with rhabdoid
phenotype, with chest wall invasion. Mediastinal lymph nodes showed no malignancy but did show
changes of Histoplasma. On post-op day 5, the patient developed hemorrhagic shock and acute
abdominal pain and a 3gm drop in hemoglobin. CT scan showed an enlarged heterogeneous spleen,
likely due to a splenic hematoma with hemoperitoneum. He underwent emergent exploratory
laparotomy where he was found to have complete disruption of the spleen, 2.5 liters of old blood within
the abdominal cavity and a large amount of clot around the spleen. Emergent splenectomy was
performed. Pathology from the spleen demonstrated disrupted spleen with abundant blood clot and
degenerating granulomata containing Histoplasma. Subsequent urinary Histoplasma antigen and serum
Histoplasma antibody were both negative. HIV ELISA was also negative. Due to plans for further
chemotherapy, he was started on oral itraconazole
DISCUSSION: Undiagnosed histoplasmosis caused acute splenic rupture in our patient; we propose that
his recent chemotherapy resulted in dissemination of his quiescent infection. One case of disseminated
Histoplasmosis causing splenic rupture was previously described in a patient with rheumatoid arthritis
on Infliximab and methotrexate. Another case of histoplasma reactivation in a patient with CLL receiving
fludarabine and alemtuzumab causing haemophagocytic syndrome has been reported. To our best
knowledge, this would be the second reported case of Histoplasma causing splenic rupture. Reactivation
of Histoplasma by biologic agents has been widely reported. There is limited data on Histoplasma
reactivation in cancer patients receiving standard chemotherapy. Further study is needed to determine
whether screening for Histoplasma in endemic areas can prevent severe sequelae in patients receiving
chemotherapy or biologic agents
302

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Quratulain Aziz, MBBS
Stop! Think, and decide? A rare but life threatening effect of dabigatran
Quratulain Aziz, MBBS. Abdur Rehman, MD. Nasir Khan, MD.
INTRODUCTION:Dabigatran etexilate is a direct thrombin inhibitor, approved by the FDA for the
treatment of non-valvular atrial fibrillation (AF). In Europe and Canada, it has also been approved for
prophylaxis of venous thromboembolism after major orthopedic surgery. Although it is considered a life
saving medicine, it is associated with several significant adverse effects, including bleeding.
Gastrointestinal tract bleeding is one of the most common complications reported in literature. We
report a rare, spontaneous epidural hematoma secondary to Dabigatran therapy.
CASE PRESENTATION: A 68-year-old Caucasian male presented to the ER with sudden onset of
unprovoked severe neck pain followed by progressive weakness in his legs and arms. His past medical
history was significant for chronic persistent non-valvular AF. He had been taking warfarin for a nineyear
period as a preventative measure for stroke. Ten days prior to admission he was switched to
standard low dose Dabigatran. A CT of the spine revealed large epidural hematoma from C2 to C7. The
patient was immediately taken to the OR where a successful evacuation and laminectomy was
performed by a neurosurgeon. The patient experienced profound improvement in his weakness over
the course of his five-day hospital stay. It was decided by his Cardiologist to forgo any anticoagulation
medication for three months. He was then transferred to sub acute rehab facility.
DISCUSSION: Dabigatran has shown clear advantages over warfarin, but still is associated with risk of
major bleeds, which usually occur at higher doses. This patient experienced Dabigatran induced bleeding
in a relatively rare site, while receiving a standard low dose. Our case highlights that caution should be
made before switching patients, who have had stable INR on warfarin for years, to Dabigatran.
303

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Pavan Kumar Bhamidipati,
MD
pegASParginase induced hyperbilirubinemia,hypertriglyceridemia and acute pancreatitis
Pavan Kumar Bhamidipati, MD Additional Authors: Suneel Vallabhaneni MD, Elias Jabbour MD,
Goutham Borthakur MD
INTRODUCTION: Asparaginase has been the cornerstone of chemotherapy in the management of
pediatric and adult ALL for almost 3 decades. Its use has been proven to add survival advantage for
these patients. Its causal role in pathogenesis of hypertriglyceridemia or acute pancreatitis is poorly
understood and it’s thought that hypertriglyceridemia is the inciting event for pancreatitis.Even though
newer forms of Asparaginase are being used, the side effect profile seems to be the same particularly
with long acting pegylated form (pegASParaginase). Exact Incidence of pegASParaginase induced acute
pancreatitis in adults is unknown and is estimated to be 7-10%. Here we present a case of an adult who
developed hyperbilirubinemia, hypertriglyceridemia and acute pancreatitis while on treatment with
pegAsparaginase for newly diagnosed ALL got successfully treated with insulin drip, antibiotic and
fibrates.
CASE PRESENTATION: 55 year old Caucasian male who was diagnosed with Ph+ALL 6 months ago
started complaining of increased fatigue and tiredness of 1 month duration.He was seen at MD
Anderson cancer center for management. His bone marrow reveled 45% lymphoid Blasts.He started
treatment with hyperfractionated CVAD and Dasatinib with no response. He was started on a
chemotherapy protocol containing methotrexate,vincristine,PegASParaginase and dexamethasone.
PegASParaginase 5000 international units were given for 2 days per cycle. The first 3 cycles were
uneventful with good response but on the 17 th day of 4 th cycle (C4D17), he had abdominal pain and
nausea and presented to ED. Amylase was 896, lipase 4467, triglycerides 2321, cholesterol 243, bilirubin
8.2.Lipid panel, LFTs, amylase and lipase 10days ago were normal. CT abdomen showed acute
pancreatitis. He was started on regular insulin drip, Meropenem and fenofibrate. His lipase, amylase
normalized in 3days. Repeat CT-abdomen showed diminished inflammation with no pancreatic necrosis
or any pseudocyst formation. He was able to tolerate diet 10 days later. But in view of this complication,
he was deemed to be not a candidate for further asparaginase use. Due to interruption of therapy
because of this complication his leukemia progressed.
DISCUSSION: Adverse effects including hyperglycemia, hyperbilirubinemia, hypertriglyceridemia, acute
pancreatitis and liver failure are more common in adult population being treated with asparaginase
compounds. There are no set guidelines neither to monitor or any effective management strategies to
treat these side effects. It is prudent to monitor adults that are being treated with pegASParaginase
closely with high index of suspicion. A recent consensus report published discourages repeat use of
asparaginase in patients with this significant toxicity. Although successful management of acute
pancreatitis in this setting with the use of octreotide or continuous regional arterial infusion of a
protease inhibitor (Nafamostat mesylate) has been reported, further confirmation is needed.
304

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Pavan Kumar Bhamidipati,
MD
A rare and lethal cause of hematuria that lead to the diagnosis of sickle cell trait
Pavan Kumar Bhamidipati, MD Shrinivas kambali MD, Suneel Vallabhaneni MD, B Babu Paidipaty MD,
Steven L Jensen, MD, Bei Fang Liu, MD
INTRODUCTION: Renal medullary carcinoma (RMC), the seventh sickle cell nephropathy, is a rare
malignant tumor arising from collecting duct epithelium. This tumor is almost exclusive to young
African-Americans with sickle cell trait (SCT).These tumors have a worse prognosis and are usually
metastasized at the time of diagnosis. So far, around 120 cases of RMC are reported in the literature.
We present an elderly black female with multiple ED visits for persistent hematuria, initially got treated
as UTI, ultimately got diagnosed with this rare condition and found to have SCT.
CASE PRESENTATION: 57 y/o African-American female presented to ED with 1week history of right
flank pain, increased urinary frequency and pink urine. Past history includes diabetes, hypertension and
papillary carcinoma of thyroid. Urinalysis showed large blood with trace esterase, 53 RBC and 7 WBC.
Renal ultrasound revealed diffuse atrophy and small cystic lesions bilaterally. She was discharged on
antibiotics for UTI. She returned to the ED 2 weeks later with similar symptoms. Repeat urinalysis
showed numerous RBC. Renal ultrasound showed a 5.5cm cystic structure in right mid-upper pole and
CT abdomen depicted solid suprarenal mass. MAG-3 scan demonstrated a severely diminished flow to
this kidney. Radical nephrectomy with lymph node dissection was done and the tumor was found to be
extending into the vena cava completely occluding it both proximally and distally. RMC, pathological
stage T3N1Mx was diagnosed. Near 100% association of this tumor with SCT prompted Hemoglobin
electrophoresis, which revealed SCT pattern with Hemoglobin-A of 78% and Hemoglobin-S of 19%.She
was discharged home in a stable condition.
DISCUSSION: RMC is extremely rare tumor and it is unclear why it occurs only in SCT/SCD patients.
Several genetic abnormalities have been proposed and it is thought to be from acidic and hypoxic
environment of the renal medulla that promotes RBC sickling leading to this malignancy. This case
underscores the importance of thorough workup through cytologic examination of urine and CT imaging
in those with SCT/SCD presenting with persistent hematuria and/or flank pain. Awareness and early
diagnosis of this tumor may improve survival among this cohort.
305

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Somy S George, MD
Propofol use in a patient with neuroleptic malignant syndrome inducing hyperthermia
Somy S George, MD Second Author: Swati Choudhary, MD; Narendra Khanchandani,MD; Mark
Villenueve, MD
INTRODUCTION:Neuroleptic malignant syndrome (NMS) is a life threatening neurologic emergency
associated with the use of neuroleptic agents and characterized by a distinctive clinical syndrome of
mental status change, rigidity, hyperthermia and dysautonomia. Central dopamine receptor blockade in
the hypothalamus may cause hyperthermia and other signs of dysautonomia. Propofol has been
commonly used as a sedative in the intensive care unit and is generally considered safe. Case reports
have shown that Propofol can cause hyperthermia in patients who have predisposing factors such as
neuroleptic malignant syndrome.
CASE PRESENTATION: Patient was a 41 year old caucasian female with past medical history significant
for Diabetes Mellitus Type II, Bipolar Disorder and Hypertension was admitted with acute respiratory
failure, altered mental status, and a temperature of 104. She was intubated and broad spectrum
antibiotics were given for suspicion of pneumonia. Pan-culture was done which showed no bacterial
growth. Her home medications included Benztropine, Chlomipramine, Clonazepam, Lamotrigine,
Lithium and Ziprasidone. All her medications were stopped on the day of admission secondary to the
possibility of Serotonin Syndrome versus Neuroleptic Malignant Syndrome (NMS). She was started on
Propofol drip due to agitation and was weaned off slowly within 3 days. Fever resolved within 2 days of
admission. Patient was extubated on day 4 but then was re-intubated the following day secondary to
continuing respiratory failure. During second intubation, jaw clenching was noticed and one dose of
succinylcholine was given for rapid sequence intubation and Propofol was restarted. Patient’s
temperature slowly started to rise with a rate of approximately 1 degree F/day to a maximum of 107 F.
Propofol was then discontinued and patient was given Dantrolene and Bromocriptine for possibility of
malignant hyperthermia. Her temperature started decreasing to normothermia within 2 days after
discontinuation of Propofol. During the time of her hospital stay, the patient developed multi-organ
failure. Due to patient’s poor prognosis the family made her hospice and she passed 19 days after
admission. Multiple factors were responsible for hyperthermia, including NMS, use of succinylcholine,
and propofol. But due to the duration of onset of hyperthermia, propofol was the most likely culprit.
DISCUSSION: Propofol should be used cautiously in patients who have mulitple risk factors to
hyperthermia. Alternative sedative agents should be used. Further studies need to be done to
understand the exact mechanism of hyperthermia caused by propofol in these high risk patients.
306

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Salwa Hussain, MBBS
Bicalutamide induced hepatotoxicity; a rare adverse effect
Salwa Hussain, MBBS, Jeffrey Najor, Ahmer Ali, MD
INTRODUCTION: There are extremely small number of cases reported in literature that highlight the
hepatotoxic potential of bicalutamide, a nonsteroidal antiandrogen used extensively during the start of
androgen deprivation therapy with a luteinizing hormone-releasing hormone agonist to reduce
occurrence of the symptoms of tumor flare in patients with metastatic prostate carcinoma. The most
common adverse effects of bicalutamide are induced by its pharmacologic property of competitive
androgen receptor blockade and include gynecomastia, hot flashes, fatigue, and decreased libido.
Although not as common, increases in liver function test results are also seen with bicalutamide therapy.
These elevations are typically transient, and patients remain asymptomatic. We share our experience of
a case of symptomatic acute hepatoxicity secondary to the use of Bicalutamide and employ this
opportunity to present a brief review of existing literature.
CASE PRESENTATION: We report the case of an 81 year-old African American male with a metastatic
prostate cancer who presented with nonspecific symptoms of decreased appetite, lack of energy,
generalized weakness and feeling off balance for three days and jaundice for one day. He also reported
dark colored urine for one week. He was started on a trial of Bicalutamide 3 weeks prior to presentation.
On physical exam, scleral icterus was noted. Workup revealed acutely elevated liver enzymes(more than
5 times the upper limit of normal) , alkaline phosphatase, conjugated hyperbilirubinemia and
coagulopathy. US abdomen was negative for obstruction. Other etiologies including viral, common
toxins and drugs, autoimmune and ceruloplasmin induced insult were ruled out. Bicalutamide was held
and patient managed with supportive care. He showed clinical improvement and normalization of the
above labs within days.
DISCUSSION: This case highlights the hepatotoxic potential of Bicalutamide. The largest study to date
addressing steroidal and non steroidal antiandrogen induced hepatoxicity was conducted in Spain in
2005, employing the Spanish pharmacovigilance database. It, however, remained inconclusive for
Bicalutamide induced hepatotoxicity due to the scarcity of reported cases by physicians, pharmacists
and nurses. Our case reviews literature on the topic and is a valuable addition to this life threatening
adverse effect of Bicalutamide
307

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Salwa Hussain, MBBS
An Atypical Presentation Of Pancreatic Cancer
Salwa Hussain, MBBS, Jaspreet Kaur Ghumman, DO. Dept. of Internal Medicine and Dept. of
Gastroenterology, Providence Hospital, Southfield, MI
INTRODUCTION:Pancreatic carcinoma is a debilitating disease and carries a poor prognosis. The
incidence of pancreatic adenocarcinoma directly invading the gastrointestinal tract leading to
gastrointestinal hemorrhage is very low. Here, we describe one unique case manifesting
characteristically severe and unremitting hamatochezia as an initial presentation of pancreatic
adenocarcinoma.
CASE PRESENTATION: A 75 year old African American man presented initially with hematochezia for 1
week with no other alarm symptoms. Physical exam was negative except for melanotic stool and
absence of bright red blood on rectal exam. Initial labs in the office showed normocytic anemia.
Scheduled colonoscopy revealed left sided diverticulosis and some melanotic stool with blood seen
throughout the colon. Emergent EGD was performed revealing an ulcerated mass in the third part of
duodenum covered by an overlying adherent clot with no active bleeding. A decision was made not to
dislodge the clot and patient was admitted for further investigation. Subsequent CT of the abdomen and
pelvis revealed multiple liver lesions and a nonspecific, 4cm cystic mass in the abdominal midline. A liver
biopsy followed but was inconclusive. Repeat EGD was performed to obtain biopsy which reported a
well differentiated adenocarcinoma and benign duodenal mucosa. Endoscopic ultrasound for further
evaluation, thereafter, revealed a pancreatic head mass with invasion in to the duodenal wall, as well as
vascular involvement.
DISCUSSION: There are a few cases reported in literature where major digestive hemorrhage was the
first sign of a subsequently proven pancreatic malignancy. The most characteristic sign of pancreatic
carcinoma of the head of pancreas is painless obstructive jaundice. Clinicians should be aware that
pancreatic malignancy may present with a varying spectrum of GI bleeding ranging from occult to
potentially exsanguinating hematemesis, hematochezia, or melena.
308

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Mayuri Sunil Jagirdar, MD
An Interesting Case of Catamenial Hemopneumothorax
Mayuri Sunil Jagirdar, MD Huda Elhwairis MD Basim Towfiq MD
INTRODUCTION:
Thoracic endometriosis is a rare disorder with presence of endometrial tissues within the pleura, lung
parenchyma and airways. Clinical presentation includes spontaneous pneumothorax and hemothorax
occurring in relation to menses which is referred to as Catamenial.
CASE PRESENTATION: A 26Y/AA/waitress with no PMH, non smoker, presented with complaints of
progressive shortness of breath for one month. She complained of decreased appetite, weight loss of
about 8lbs over 1 month and abdominal cramps due to menstrual cycle. Examination showed a thin
appearing female with BMI of 17 and no significant findings except tachypnea. Pleural effusion was
noted clinically which was confirmed with chest radiograph. Labs were unremarkable except for mild
anemia and mildly elevated CA-125. Pleural fluid on aspiration was grossly bloody with RBCs but
negative for lymphocytes and malignant cells. Approximately 3000cc was drained in 24 hours. A chest
tube was placed and output was less than 150cc in 24hrs. Follow up chest x-ray showed development of
Tension Pneumothorax. She underwent Video Assisted Thoracoscopy and Mini thoracotomy which
showed air leaks in right middle lobe which was resected. She underwent Abdominal Laparoscopy to
find the cause for ascites and right Thoracotomy as she had continued air leaks post-operatively. The
abdominal laparoscopy showed hemoperitoneum with small chocolate cysts along the rectovaginal
septum with extensive adhesions. The posterior aspect of the uterus showed a ruptured chocolate cyst
with fresh bleeding and clots. Right thoracotomy revealed multiple fenestrations in the diaphragm and
presence of endometrial implant which were the source of air leaks along with a large bulla. The
fenestrations were sealed and the bulla was resected and a chest tube was placed. She improved
clinically with no air leaks from the chest tube. She was given a Lupron injection for suppression of the
Hypophyseal gonadal axis and to follow up on outpatient basis. She has shown no signs of recurrence for
5 months since discharge.
DISCUSSION: This case illustrates the clinical presentation of Catamenial hemopneumothorax. Most of
the cases reported were young reproductive African American females with involvement of the right
side of the chest. Along with clinical suspicion, diagnosis is confirmed with Video Assisted Thoracic
Surgery. Treatment consists of GnRh analogues to suppress the HPA axis and surgical management,
although 50% recurrence rate is reported.
309

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Shwan Mohamod Dhahir
Jalal, MBChB
A Case of Death Due to Ibogaine Use for Heroin Addiction
Shwan Mohamod Dhahir Jalal, MD, MBChB, Edouard Daher MD, FACP, Raymond Hilu MD, FACP
INTRODUCTION: Ibogaine is a natural psychoactive substance that is found in a number of plants
known as Iboga in Africa. It is widely used in Gabonian initiation ceremonies which is known to cause
near-death experiences. Ibogaine has been used to treat opioid and cocaine addiction because of its
effectiveness in reducing withdrawal symptoms, and decreasing craving. However, in the United States
and most European countries, Ibogaine use is prohibited due to reported deaths. Ibogaine has a
complex mechanism of action through different neurotransmitters. Which includes NMDA receptor
antagonists, the serotonin transporter, and putative agonists on Kappa- and Mu-opioid receptors.
Ibogaine a can also decrease ethanol consumption through Increased glial cell line-derived neurotrophic
factor (GDNF) in the ventral tegmental area. Ibogaine can cause sudden death by cardiac and non-
cardiac means. It can cause QT interval prolongation, and induce heart failure secondary to autonomic
imbalance caused by sympathetic over activity from the left cerebral hemisphere. Non cardiac causes
include respiratory failure.
CASE PRESENTATION: Our patient is a 25 year old gentleman with past medical history of SVT treated
with RF ablation, and pacemaker placement at age of 11. He was a heroin addict with a long history of
unsuccessful attempts of detoxification including methadone. He decided to try Ibogaine. After taking
2.5 grams of Ibogaine over 3 hours, the patient started to have hallucinations, ataxia, muscle spasms,
weakness, fever, and urinary retention. Later that day most of those symptoms resolved except for
muscle spasms and ataxia. He developed respiratory difficulty overnight followed by cardiopulmonary
arrest the following morning. The patient was successfully resuscitated on the field and was brought to
the hospital, and then transferred to the ICU. On physical exam the patient was in a decorticate position,
had muffled heart sounds, and coarse breath sounds bilaterally. Initial labs showed WBC24.5, Hgb13.8,
BUN36, Cr.2.61,AST 1099,ALT 491,Troponin2.39,and CPK 10,535. A CT of the brain revealed cerebral
edema. Echocardiogram showed EF 10% with severe global hypokinesis. The patient expired after 2 days
from multiorgan failure.
DISCUSSION: There is evidence from animal studies to suggest that Ibogaine can reduce withdrawal
symptoms and craving of addiction . However, there have been no rigorous scientific clinical trials
conducted in humans. With the increase in the number of ibogaine users around the world, it is
necessary for more research in humans to help elucidate more information regarding the efficacy and
safety of Ibogaine. We present this case to bring awareness to health professionals of the use of
ibogaine by addicts and its dangers and toxicity.
310

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Joe Marie Jose-Dizon, MD
Cannabinoid hyperemesis: Cyclical vomiting and Compulsive Bathing
Joe Marie Jose-Dizon, Parul Sud, Siva Talluri, Siddesh Besur
INTRODUCTION: Cannabis is one of the most commonly abused recreational drugs in the United
States, and now is being widely approved for medicinal purposes. Chronic use is associated with
pulmonary, reproductive and psychosocial disorders. We report a rare case of cannabinoid hyperemesis
syndrome and its economic impact.
CASE PRESENTATION: A 41-year-old Caucasian female presented to the emergency room with a fiveday
history of vomiting recurring every fifteen minutes. The vomitus was non-bloody, non-bilious and
was associated with epigastric pain. Symptoms were relieved by hot baths, and she reported up to fifty
per day. Past medical history included hypertension, myocardial infarction and cholecystectomy.
Personal history was remarkable for daily cannabis use for twenty years. On physical examination, vital
signs were normal. The abdomen was soft with epigastric tenderness and normal bowel sounds. Workup
including complete blood count, renal and liver function tests, serum amylase and lipase were
normal. Her urine pregnancy test was negative and urine toxicology was positive for
tetrahydrocannabinol. The computerized tomography scan of the abdomen, upper gastrointestinal
endoscopy, and colonoscopy were normal. Intravenous fluids and antiemetics resulted in symptom
resolution. We made a diagnosis of cannabinoid hyperemesis syndrome based on her chronic cannabis
use, persistent vomiting and compulsive bathing. She was counseled and referred to a substance abuse
program. Unfortunately she continued to use cannabis with recurrent episodes resulting in multiple
hospital admissions over the next five months. When seen in the clinic on follow up after six months,
she had been off marijuana for one month and had been asymptomatic. Total cost to date for this
patient’s multiple ER visits and admissions is $80,000.
DISCUSSION: Cannabinoid hyperemesis syndrome is known to occur in chronic marijuana users. It is
associated with recurrent nausea, vomiting and abdominal pain and is alleviated by hot baths. The fat
solubility of cannabis prolongs its half life and leads to chronic stimulation of CB1 receptors. The
recurrent vomiting is proposed to occur when CB1 receptors in the gut override CNS receptors and
suppress peristalsis and gastric emptying. The relief associated with warm bathing is thought to be due
to stimulation of CB1 receptors in cutaneous vessels, causing a cutaneous steal syndrome. There is a
temporal relationship between cannabis use and the onset and resolution of symptoms.
Cannabinoid hyperemesis syndrome should be considered in patients presenting with abdominal pain
and recurrent vomiting in the setting of chronic marijuana use.
311

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Zaid Kasmikha, DO
Is it possible? Clozapine Induced Hemorrhagic Pericardial Effusion Causing Cardiac Tamponade
Zaid Kasmikha, DO, Timothy Larsen, DO, Zaid Yaldo, MD, Sachin Amruthlal-Jain, MD, Jamal Zarghami,
MD, Shukri David, MD
INTRODUCTION:Clozapine is an atypical antipsychotic frequently used in the treatment of
schizophrenia, often in patients who have failed other therapies. Tachycardia and orthostatic
hypotension are well-recognized cardiovascular adverse effects of the drug, occurring in up to 25% and
9% of patients, respectively. There is increased concern about the more serious cardiac adverse
reactions in patients taking Clozapine, such as pericarditis, myocarditis and cardiomyopathy. Herein, we
report a rare case of Clozapine induced hemorrhagic pericardial effusion.
CASE PRESENTATION: A 58 year old African American male with a longstanding history of
schizophrenia controlled with Clozapine 750 mg daily for about one year, presented to the emergency
room with complaints of chest discomfort, fatigue, tachycardia and progressive shortness of breath.
Symptoms were non-remitting resulting in acute respiratory failure requiring intubation and ICU
management. A 12-lead EKG revealed low QRS voltage with electrical alternans. Echocardiogram
identified a large pericardial effusion with tamponade physiology. Pericardiocentesis performed at
bedside removed 350 mL of hemorrhagic fluid. Pericardial fluid analysis revealed a high red cell count
with a normal white cell count, while gram stain, bacterial culture, AFB stain and culture were all
negative. Extensive serologic studies including rheumatioid factor, ANA, sedimentation rate, fibrinogen
levels, ribonucleoprotein-peptide, TSH, C3, C4, HIV serology, anti-smith antibody, anti-double stranded
DNA antibodies, and Cocksackie A/B antibodies were performed. Of these, only rheumatoid factor, ANA
and sedimentation rate were remarkable. Approximately 1300 mL of hemorrhagic pericardial fluid was
drained over 5 days. With an essentially negative workup, Clozapine was suspected as a potential
etiology. After its discontinuation, the patient’s symptoms improved and the pericardial drainage
ceased. Repeat echocardiogram showed no recurrence of the pericardial effusion.
DISCUSSION: Although cases of Clozapine induced pericardial effusion are rare, it has been reported in
the literature. Our case demonstrates that the hemorrhagic pericardial effusion was iatrogenic for the
following reasons. First, other etiologic factors that could have caused pericardial effusion were
excluded. Second, our patient lacked cardiovascular risk factors and symptomatic pericarditis in an
otherwise healthy, young individual is uncommon. Third, the effusion resolved after discontinuation of
the offending agent, Clozapine. The Naranjo Probability Scale identified our patient’s pericardial effusion
as a probable adverse drug reaction secondary to Clozapine. An appropriate medical history and physical
examination is warranted prior to initiating Clozapine. Early recognition and intervention is vital to
prevent serious cardiac adverse reactions.
312

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Eve E Kenfack, MD
An Unusual Emerging Complication Of H1N1 Influenza Disease
Eve E Kenfack MD, Jean Fotso MD, Abhilasha Pandey MD, Vijayalakshmi Nagappan MD, Ghadi Ghorayeb
MD.
INTRODUCTION: Mediastinitis is a life-threatening emergency. In the Unites States, most cases are
related to cardiovascular surgery with Staplylococcus aureus as pathogen. In patients who have not
undergone surgery, the two most common causes are esophageal rupture and descending
mediastinitis with Streptococcus and anaerobes leading the list of causative agents. We report the first
case of methicillin-resistant Staphylococcus aureus acute mediastinitis after H1N1 influenza infection.
CASE PRESENTATION: A 60 years old female with history of asthma, coronary disease and diabetes
presented to our emergency room with right sided chest pain and worsening dyspnea. This was her third
presentation to the emergency room for the past 10 days. Her initial symptoms were dyspnea,
wheezing, dry cough and subjective fevers and chills for which she was treated for asthma exacerbation.
The nasopharyngeal rapid antigen test returned positive for influenza A. She was started on oseltamivir
and was discharged after 5 days. Her symptoms waxed 2 days later and she went to another
hospital. Her chest X rays had remained unremarkable. She was discharged 48h later after another
course of bronchodilators and steroids with antibiotics. She returned to our facility 24h later. Her
shortness of breath had worsened, she had developed right sided chest pain extending to the neck. On
examination, there was excruciating tenderness on the right side of the chest. No crepitus, no swelling.
Normal oral and skin exam. White count was 26.9.The repeated chest X ray showed a widened
mediastinum and haziness at right lung base. A CT scan of the chest revealed complex right-sided
effusion, large opacity in the right paratracheal area and diffuse haziness in the posterior mediastinum
suspicious for mediastinitis. Esophagogram: no evidence of esophageal perforation. CT-neck: no abscess.
CT-thoracentesis: purulent effusion. A cardiothoracic surgeon was consulted. Intraoperative findings
were consistent with purulent mediastinitis. The patient underwent an urgent right thoracotomy with
debridement of mediastinal abscess, mediastinal lymphadenectomy, and decortication of the left lung.
Broad spectrum antibiotics were started. Cultures of the mediastinal abscess, the pleural fluid as well as
blood and sputum grew methicillin resistant Staphylococcus aureus. She was continued on vancomycin.
Influenza A PCR of nasopharyngeal aspirate: positive for H1N1. She was continued on oseltamivir. Her
symptoms improved. On day 15, she was discharged to a long term acute care facility.
DISCUSSION: The most common complication of H1N1 influenza is fulminant pneumonia. Benign
pneumomediastinum and subcutaneous emphysema have been described in children. After infection
with H1N1 flu, our patient developed a staphylococcal superinfection causing severe mediastinitis and
a right empyema. A smaller proportion of acute mediastinitis is caused by the extension of pneumonia,
lung abscesses and pleural empyema. We believe that the severe mediastinitis was secondary to an
extension of the right empyema into the mediastinum.
In summary, we present the second case in the literature of acute mediastinitis in the subset of H1N1
influenza disease. Physicians should be aware of mediastinitis as a potentially severe complication of
H1N1 influenza as early recognition is a key factor to survival.
313

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tejaswini Kulkami, MD
MPH
Thyrotoxic Periodic Paralysis in a young African- American patient- A case report
Tejaswini Kulkami, MD MPH; Manisha Srinivasa MBBS; Samantha Staley MD; Kamalakar Nerusu MD
INTRODUCTION: Hypokalemic periodic paralysis is a rare and potentially lethal complication of
hyperthyroidism characterized by proximal muscle paralysis and hypokalemia with biochemical evidence
of thyrotoxicosis. Many affected patients may not have obvious symptoms and signs of hyperthyroidism.
These patients will spontaneously recover muscle strength without treatment but potassium
supplementation will prevent cardiac arrhythmias and hasten recovery during the acute phase.
Thyrotoxic Periodic Paralysis (TPP) is a disease of young Asian males and the incidence in North America
was reported to be only around 0.1% in thyrotoxic patients. However, with increasing population
mobility and admixture, TPP as the presenting feature of hyperthyroidism has increased in Western
countries.
CASE PRESENTATION: A 24-year-old African American male with no past medical history presented
with sudden onset weakness in his thighs and arms which progressed to an inability to move his
extremities. The patient reported experiencing at least six such transient, self-resolving episodes in the
past one year. He did visit his primary care physician but no diagnosis was made. On a review of
symptoms, he stated that he had episodes of palpitations and tremulousness, was intolerant to high
temperatures and had lost weight. He denied any skin or hair changes and changes in his bowel
movements. He was not on any home medications. He had a family history of Grave’s disease in that
both his maternal and paternal grandmothers, both his parents and two siblings were affected.
However, none of these members had a history of paralysis. On exam, he was tachycardic with a heart
rate of 104; his thyroid was diffusely enlarged; he had no exophthalmoses or tremors. His weakness had
improved considerably at this time and motor test showed mild to moderate weakness in bilateral
proximal arm and thigh. Initial laboratory tests revealed potassium of 2.6, magnesium of 1.4 and
creatinine phosphokinase level of 1127 with normal urine potassium. TSH was found to be less than
0.002 (0.5-6µIU/L), T3 was 551(1.71-3.71pg/dl) and T4 was 22.5(0.7 -1.48 ng/dl). EKG showed sinus
tachycardia. Ultrasound of the thyroid showed mildly enlarged gland with increased vascularity but no
nodularity. A diagnosis of hypokalemic paralysis due to thyrotoxicosis was made. Potassium was
adequately replaced and monitored. He was started on propylthiouracil 100 mg every 8 hours. His
symptoms resolved and he was discharged home with a follow- up appointment for further
management.
DISCUSSION: This condition is rare in African- Americans and can be frequently overlooked and
misdiagnosed on presentation. A high degree of physician awareness is required to recognize the
association with thyroid disease especially when patients present with unexplained hypokalemia,
muscular weakness and rhabdomyolysis.
314

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Navneet Kumar, MD
An unusual complication of weight lifting: Aortic Dissection!
Navneet Kumar, MD Other Authors: Navneet Kumar, MD, Asad Omar, MD, Samira Ahsan, MD
INTRODUCTION:Aortic dissection (AD) is a catastrophic event secondary to number of known
precipitating factors (Kamalakannan, 2007). Weight lifting, on the contrary is a rare causes of AD.
Researchers from Yale University School of Medicine reported 31 patients having AD precipitated by
weight lifting, of which 4 had Sanford Type B. Extensive literature search showed most articles describe
Sanford Type A AD and with existing aortic dilation presenting with acute onset chest pain after weight
lifting. We report a rare case of non-Marfan elderly patient with localized intimal dissection in non
dilated infrarenal abdominal aorta (Sanford Type B/ DeBakey's Type IIIb) presenting as sudden onset
abdominal pain after weight lifting.
CASE PRESENTATION: 60- year old African-American gentleman presented with a 3-day history of
acute onset left lower quadrant abdominal pain which started while moving his friend’s heavy furniture.
Clinical examination revealed mild left lower quadrant abdominal tenderness on deep palpation with
otherwise normal exam. Vitals and routine labs were within normal limits. EKG showed sinus. Contrastenhanced
CT scan of abdomen/pelvis revealed localized infrarenal abdominal aorta intimal dissection
from origin of inferior mesenteric artery, extending approximately 3cm caudally. No retroperitoneal
hemorrhage. Aortic diameters were 1.8x1.9cm in transverse and AP planes respectively. No CT/clinical
evidence of bowel ischemia were apparent. No history/clinical evidence of Marfan's syndrome/ Ehlers-
Danlos' syndrome/syphilis/vascular anomaly/trauma were noted. Conservative management was
started. Beta blocker was given to maintain heart rate

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Leonardo E Lopez, Jr MD
Spontaneous visceral artery dissection
Leonardo E Lopez, Jr MD Second Author: Mohammed Ibrahim MD
INTRODUCTION: Spontaneous visceral artery dissection is a rare event, especially in the digestive
arteries. Even rarer is the occurrence of a true spontaneous celiac artery dissection. Potential
complications include ischemia of the organs supplied, aneurysm formation, arterial rupture and
bleeding. We report a case of an acute splenic infarction secondary to a spontaneous dissection of the
celiac artery.
CASE PRESENTATION: A 44-year-old male non-smoker presented to our emergency center for suddenonset
left upper quadrant abdominal pain, non-radiating, which was described as sharp and
stabbing. He denied any other associated symptoms. His past medical history was negative for
coagulopathy , hemoglobinopathy, hyperlipidemia, hypertension, heart disease or intravenous drug
use. He denied any significant trauma to the abdomen. On admission, tests for hepatic and pancreatic
etiologies were negative. A computed tomography (CT) scan of the abdomen showed an acute splenic
infarction. Hypercoagulability testing and sickle cell screen were negative. An initial abdominal duplex
scan did not reveal any vascular compromise to the spleen, but an abdominal CT angiography showed an
arterial dissection originating in the celiac artery, extending into the common hepatic and splenic
arteries, causing splenic perfusion compromise. Inflammatory causes of dissection were ruled out.
During the admission, he had hypertensive episodes. He was managed conservatively with
anticoagulation using heparin drip then warfarin (target INR 2-3), and tight blood pressure control. At
his sixth month follow up, he was asymptomatic and doing well. Repeat CT angiography of the
abdomen redemonstrated a proximal celiac artery dissection.
DISCUSSION: Spontaneous celiac artery dissection as a differential diagnosis for acute abdominal pain
with splenic infarction can be missed due to its rarity. There are only less than 30 reported cases in the
literature. The patients are predominantly middle-aged men. The cause is still unknown. Risk factors
include atherosclerotic disease, hypertension, fibromuscular dysplasia, trauma and connective tissue
disease. Epigastric pain is a cardinal symptom, but the lesion may be asymptomatic. Uncomplicated
cases are usually successfully managed medically with close monitoring.
316

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ridhwi Mukerji, MD
Modern Milk Alkali Syndrome: A Case Report
Ridhwi Mukerji, MD Siva Talluri, MD Siddesh Besur, MD
INTRODUCTION: Hypercalcemia is a common clinical problem. We discuss a modern variant of milk
alkali syndrome (MAS) secondary to calcium carbonate ingestion.
CASE PRESENTATION: A 69 year-old female presented with progressive weakness, intractable nausea
and vomiting. Past medical history was significant for hypertension, GERD and hiatal hernia. Medications
included lisinopril, hydrochlorothiazide and over-the-counter (OTC) Tums®. Examination showed only
signs of dehydration. Laboratory revealed acute renal failure, metabolic alkalosisis, hypokalemia and
hypercalemia. Malignancy was ruled out after a work-up that included CT scan of head, chest, and
abdomen. Patient’s vitamin D and serum phosphorus levels were low. Intact parathormone,
parathormone-related peptide and serum and urine protein electrophoresis were normal. Patient was
hydrated and received one dose of pamidronate 90 mg resulting in hypocalcemia requiring treatment.
After a hospital stay of twelve days, the patient was discharged with normal biochemical
parameters. Without other identifiable causes and with the patient’s history of OTC Tums® usage,
along with the typical clinical presentation, the patient was diagnosed to have MAS.
DISCUSSION: Over the last couple of decades, the incidence of MAS as a cause of hypercalcemia has
been found to be as high as 12%.The classic triad consists of hypercalcemia, metabolic alkalosis, and
renal insufficiency secondary to ingestion of large amounts of absorbable alkali and calcium. Daily
elemental calcium intake of two grams or less is considered safe, however lower doses have been
shown to cause MAS due to predisposing factors like abnormal kidney function, inability of the skeletal
system to buffer calcium, individual variations in buffering capacity, thiazide diuretic use or excessive
vomiting. The hypercalcemia and metabolic alkalosis result in a positive feedback loop producing the
clinical picture of MAS. The low to normal phosphorus values in modern MAS are due to calcium
carbonate, acting as a phosphorus binder. Treatment is hydration, withdrawal of the offending agent
and diuretic therapy. However, in severe cases, bisphosphonates may be used with caution to avoid
hypocalcemia. Also, bisphosphonate therapy can be counterproductive since bone resorption is not
thought to be a contributing mechanism.
Renal function usually requires only supportive measures. Renal failure in MAS is thought to be
mediated by tubular epithelium degeneration and granular (presumably calcium-laden) materials inside
and around collecting tubules along with hyalinization of glomeruli and thickening of the basement
membrane.
Conclusion: The increasing incidence of MAS has been hypothesized to be a result of OTC availability of
calcium carbonate. Due to the innocuous nature of these supplements the general public is unaware of
its potential complications. History is often not forthcoming because of their OTC status. But, due to the
reversible nature of this problem, physicians and lay persons should be aware of this condition.
317

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ridhwi Mukerji, MD
Malignant Cerebral Edema Following CT Lumbar Myelogram Using Omnipaque-300 (Iohexol) Non-Ionic
Water Soluble Contrast Dye
Ridhwi Mukerji, MD Aileen M. Arguelles, MD Shaun A. Wahab, MD Radhika Kakarala, MD
INTRODUCTION:Intrathecal injection of ionic contrast dyes have been reported to result in serious
neurological adverse effects. But to our knowledge, there is only one documented case report of
malignant cerebral edema in response to lumbar myelography using non-ionic water soluble contrast
dye. We report a second case with symptomatic and radiographic evidence of severe cerebral edema
following use of Omnipaque-300® (iohexol), a non-ionic contrast dye.
CASE PRESENTATION: A 74 year old Caucasian male was admitted to our hospital with significant
generalized weakness and chronic back pain for which he underwent a CT lumbar myelogram. Soon
after, the patient displayed increasing generalized weakness, altered mental status and slurred speech.
The exam revealed stable vital signs, papilledema, decreased reflexes and power without localizing
signs. A stat CT scan of the head showed findings consistent with diffuse cerebral edema without
midline shift. Past medical history was significant for hypertension, dyslipidemia, COPD, diabetes, CHF,
CAD and morbid obesity. Medication review ruled out side effects as a contributory cause. Review of
systems was negative. The patient was admitted to the ICU with elevation of the head of the bed and
started on dexamethasone and mannitol. Leviracetam was administered for seizure prophylaxis.
Neurosurgery consult concurred with our management. The patient’s condition improved the next day
and was asymptomatic soon thereafter. A repeat CT scan showed near complete resolution of his
cerebral edema. In the absence of other possible causes and the temporal correlation with the adverse
event, the contrast media used for the CT-myelogram was the most likely cause for the patient’s
cerebral edema.
DISCUSSION: Cerebral edema is visible radiographically as sulcal effacement and obliteration of basal
cisterns. Its consequences can be life threatening and it needs to be immediately identified. Based
upon our review of the literature, we identified several potential mechanisms for the cerebral edema as
follows: blood-brain-barrier dysfunction, indirect neuronal post-membrane action, changes in the
extracellular milieu of neurons and loss of cerebral vascular autoregulation with resulting vasogenic
edema. Our therapy was directed at the latter. The osmotherapy with mannitol allowed water
movement from the cerebral extracellular compartment into the vasculature. Steroids helped stabilize
the disrupted blood-brain-barrier. The head of bed elevation facilitated a decrease in the cerebrospinal
fluid hydrostatic pressure whereas avoidance of mechanical jugular venous compression decreased
venous outflow impedance from the cranium.
Conclusion
It is crucial for physicians to be cognizant of this rare complication, to avoid missed or delayed diagnosis
and treatment of this potentially lethal problem. Hence the reaction must be documented in the
patient’s medical record with subsequent avoidance of non-ionic contrast dyes like iohexol or pre-treat
the patient with steroids.
318

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Praneet K Nanduri, MD
Sep’tick’ shock
Praneet K Nanduri, Srinivasa Reddy Sanikommu, Padmaja Veeramreddy, Eyassu Habte-Gabr, Mitra
Tewari
INTRODUCTION: Septic shock is one of the most common presentations of hypotension in the ICU.
However if the patient is not improving with appropriate management, other causes should be sought.
CASE PRESENTATION: A 62-year-old man with a history of hypertension and diabetes mellitus
presented with headache, fatigue and dizziness. He was treated with amoxicillin for suspected otitis
media for two days prior to admission. However, his condition deteriorated rapidly and he was brought
to the ER, where he was found to be febrile, hypotensive and in acute renal failure. His WBC was 4,600
with 17% bands and platelet count was 82,000. Transaminases were also elevated, while CSF analysis
was within the normal range. HSV PCR was negative. He was admitted to the ICU with an impression of
septic shock and he was resuscitated with IV fluids, followed by pressors to maintain blood pressure.
Vancomycin and Cefepime were started pending culture results. Hemodialysis was initiated for
worsening kidney function. However, the patient’s condition continued to deteriorate in spite of
negative blood, CSF and urine cultures. On day 3 of admission, a maculopapular rash was noted in the
lower extremities beneath his compression stockings. Further examination revealed sporadic lesions on
his hips and his back, and subsequently an engorged tick was found in his retroscrotal area.
Retrospectively, we elicited a history of travel to Vancouver, Canada three months prior to the
admission and recent trip to a state park (Osage Hills) in Oklahoma. Doxycycline was started on
suspicion of a tick borne infection and serology was sent for Ehrlichia, Anaplasma, Lyme disease,
Babesiosis and Rickettsia. The tick was identified as a Lone Star tick (Amblyoma americanum). His IgG
titres for Ehrlichia chaffeensis were initially

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Monzer Saad, D.O
Singulair (Montelukast) Induced Partial Bowel Obstruction
Monzer Saad, D.O Anil Sil, MD, FRCP, FACP
INTRODUCTION: Singulair is a competitive and selective oral Leukotriene receptor antagonist that
inhibits cysteinyl leukotriene CysLT1 receptor. It is commonly used for the prophylaxis and chronic
treatment of asthma, also effective in the treatment of allergic rhinitis. Singulair is a safe and effective
drug. Clinical trials showed comparable incidences (less than 1%) of angioedema in patients using
singulair versus placebo, and slightly greater incidences of abdominal pains in singulair compared to
placebo patients.
CASE PRESENTATION: Patient is a 78 year old male with a past medical history of allergic rhinitis,
arthritis, benign prostatic hypertrophy treated with flomax, hyperlipidemia treated with zocor, and a
past surgical history of partial splenectomy in 1956, presents complaining of sudden onset nausea,
vomiting and diffuse, non-radiating severe abdominal pain. These symptoms started two hours after the
patient took the first pill of singulair, which was newly prescribed for his allergic rhinitis. Patient denies
any other systemic symptoms. No history of diarrhea, constipations, fever, chills, or similar symptoms.
The patient and his spouse consumed the same diet. His spouse didn’t develop any symptoms. Physical
examination was not significant except for diffuse abdominal tenderness on deep palpation. CT scan of
the abdomen showed some thickening of the distal esophagus. EGD was done that showed gastritis.
Singulair was stopped and the patient was started on intravenous fluids. First, he was given nothing by
mouth, but then advanced to clear liquid/soft diet after having witnessed regular bowel movements.
Shortly after, and without any pharmacological interventions, patient’s symptoms progressively
improved, and he was discharged home with the diagnosis of singulair induced angioedema causing
small bowel thickening and resultant partial bowel obstruction.
DISCUSSION: The most commonly seen singulair adverse reactions are: upper respiratory infections,
fever, headaches, pharyngitis, cough, abdominal pain, diarrhea, otitis media, influenza, rhinorrhea, and
sinusitis. This case report exemplifies a singulair induced gastro-intestinal angioedema, which is not
commonly seen or reported. Furthermore, adverse reactions are usually seen after chronic usage of this
drug, and it is not usual to be seen after taking only one pill.
320

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tiffany Sanford, MD
Levamisole-Adulterated Cocaine: A case of new rash in a cocaine abuser
Tiffany Sanford MD, Violet Asfour MD, Brenda Pellicane MD, Falgun Patel MD, Cecilia Big MD
INTRODUCTION: In the last 15 years, the drug called levamisole has been used as an adulterant in the
production of cocaine, with upwards of 70% of the US cocaine supply contaminated. It is believed that
levamisole can add to the euphoric effect of cocaine by prolonging the presence of neurotransmitters in
the synapse. Commonly used as a veterinary anti-helminth, levamisole was also used as an
immunomodulatory drug for nephritic syndrome and rheumatoid arthritis. It is now only approved in US
markets as an adjunct medication for use in colon cancer.
CASE PRESENTATION: A 36 year-old woman with a history of IV drug abuse, Hepatitis C, and
prostitution presented to the emergency room with a diffuse purple rash. She had fevers, chills and
painful blisters on both knees. The patient was initially diagnosed with a bacterial skin infection and
given antibiotics. After failed outpatient treatment, she returned with large, tender purpuric macules
with erythematous borders. The rash had spread all over the body with central ulceration and crusting
on her bilateral arms, legs, abdomen, face, and lobe of ear. Basic metabolic profile, LFT, C3, C4, UA were
normal. HIV and Rheumatoid Factor were negative. There was no growth in blood cultures. WBC count
was reduced, while D-Dimer and Fibrinogen were elevated. Urine Drug Screen was positive for opiates
and cocaine. Skin biopsy identified leukocytoclastic vasculitis. Similar presentations of leukocytoclastic
vasculitis in cocaine abusers at local hospitals lead to identifying Levamisole toxicity as the probable
cause of the purpuric rash.
DISCUSSION: Levamisole, in both medically-indicated and illicit use has been found to have some
dangerous side effects, including agranulocytosis, and leukocytoclastic vasculitis. With drug adulterants
becoming increasingly pervasive, physicians working in areas of widespread drug abuse should become
familiar with the stigmata of levamisole toxicity - purpuric skin rash and agranulocytosis.
321

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aubrey N Schmidt, MD
Sudden Left Eye Blindness with Right Eye Prosthesis
Aubrey N Schmidt, MD Other Authors: Naif Nasser,MD, Vidushi Sharma,MD, Imran Mir,MD,Assistant
Director of Internal Medicine, Synergy Medical Education Alliance
INTRODUCTION: Conversion disorder is a type of somatoform disorder that presents with motor,
sensory or visceral symptoms that suggest a neurologic or general medical condition. This disorder is
unintentional and the gain is primarily psychological not monetary or legal and is triggered by a stressor
in the patient’s life. Paralysis, blindness and mutism are the most common presentations of Conversion
disorder. It is associated with passive aggressive, dependent, anti-social, and histrionic personality
disorders.
CASE PRESENTATION: This is a 62 year old African American male with a past medical history of right
eye prosthesis since birth, diabetes type 2 and paranoid schizophrenia who presented with sudden
onset left eye blindness. The patient initially had 2 day onset of progressively worsening left eye
blindness for which he was referred from the ophthalmologist after the comprehensive eye exam
showed no pathology. He presented to the emergency department and was started on high dose
steroids for questionable temporal arteritis. All routine labs including blood counts and sedimentation
rate, rheumatoid factor, and C reactive protein were normal. The brain imaging was normal excluding
any stroke, vascular pathology, increased intracranial pressure, or tumor. The temporal artery biopsy
was performed which was negative. Subsequently Neurology and Psychiatry were consulted. Psychiatry
thoroughly investigated his personal, and psychosocial history. The patient admitted to having multiple
stressors in the last month including death of close family member and a friend, and a sister recently
diagnosed with cancer. He further admitted to having apprehension about living alone and caring for
himself with this bilateral blindness. After thorough case review, the patient was diagnosed with
conversion disorder and psychiatry recommended starting patient on anxiolytics, and antipsychotic
medication along with behavioral psychotherapy. Patient was in agreement with the diagnosis and plan,
and his symptoms slowly began improving with positive reassurance. With in the next 2 days the
patient was able to appreciate perception of light and his visual fields improved.
DISCUSSION: Onset of Conversion Disorder is usually acute and symptoms are usually of short
duration. Approximately 95% remit spontaneously within 2 weeks. Resolution of symptoms is usually
spontaneous, although it is probably facilitated by insight oriented supportive or behavioral therapy and
anxiolytics. Good prognosis is associated with acute onset, presence of clearly identifiable stressor at
onset, and short interval between onset and institution of treatment. Other good prognostic factors
include, above average intelligence, paralysis, aphonia, and blindness. Poor prognosis is associated with
seizures, and tremors.
322

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Ankur Sharma, MD
Thyroid Nodule with a punch: Renal Cell Cancer
Ankur Sharma, MD. Dept of Medicine, Sinai Grace Hospital/ DMC, Detroit, MI Second Author: Gard
Edelson, MD. Dept of Medicine, Sinai Grace Hospital/ DMC, Detroit, MI
INTRODUCTION: Metastasis to the thyroid is commonly seen in post mortem autopsies in patients’
with malignancies. However, a clinical diagnosis of the same is less common. Cancer.Metastatic cancer
of the head and neck comprises of only 8-14% of metastasis from renal carcinoma. Unfortunately, most
cases are diagnosed on autopsy, with the incidence varying from 1.25% to 24%.
CASE PRESENTATION: A patient with history of nephrectomy in 1995 for RCC had a CT of the chest in
2005, for surveillance of lung nodules where a thyroid mass was seen. Ultrasound examination revealed
a 4.9 cm right thyroid mass and subsequent nuclear medicine scan showed large cold nodules. FNA was
consistent with a benign colloid nodule.The patient was started on levothyroxine for asymptomatic
hypothyroidism. In March 2010, a CT chest showed interval increase in size of the thyroid. Aspiration of
the mass was non diagnostic. A repeat biopsy from the dominant nodule showed aggregates of thyroid
follicular cells, with minimal degree of nuclear enlargement within some follicular cells, suggesting a
follicular lesion. Right thyroid lobectomy was done and pathology identified a capsulated tumor
composed of clear cells. Immunohistochemical analysis revealed positive staining for CD10,KIM-1 and
PAX2 and negative for Thyroglobulin and TTF-1 (Thyroid transcription factor 1) consistent with
metastatic renal cell carcinoma.A whole body bone scan revealed no evidence of osseous metastatic
disease.
DISCUSSION: A solitary metachronous metastasis in the thyroid from the RCC is exceedingly rare.
However, metastasis to the thyroid is not as unusual as was previously thought. The clinical course of
renal cell carcinoma and the development of metastases may be particularly slow-paced, so far there
are 7 reports on extreme delays in metastasis to the thyroid, ranging from 3 to 26 years.
The interval of more than 5 years is long enough to distract the physician’s awareness about the
previously treated malignant disease. Although a thyroid nodule is an extremely common clinical
finding, the new appearance of a thyroid nodule in patients with previous malignant disease warrants
prompt cytological evaluation.
One potential source of confusion in cytological interpretation is the difficulty of distinguishing primary
thyroid anaplastic carcinoma from metastatic high-grade malignancy. Immohistochemical staining of
renal cell carcinoma has shown expression of low-molecular-weight cytokeratin, epithelial membrane
antigen (EMA) and vimentin, but no studies regarding the use of these markers has yet been reported.
Management of thyroid metastases should depend on the individual situation. There is no clear
consensus. Also, although therapy of metastatic malignancies is often considered to be palliative,
aggressive surgical treatment in isolated cases may be curative and of clear survival benefit.
323

MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aruna Vommi, MD
Rituximab in the treatment of ANCA Associated Vasculitis Aruna Vommi, MD, ALMansour, MD,
Department of Internal Medicine, Sinai-Grace Hospital/Detroit Medical Center, Detroit, Michigan.
Aruna Vommi, MD, ALMansour, MD, Department of Internal Medicine, Sinai-Grace Hospital/Detroit
Medical Center, Detroit, Michigan. Aruna Vommi, MD, ALMansour, MD, Sinai-Grace Hospital/Detroit
Medical Center.
INTRODUCTION: Anti-neutrophil cytoplasmic antibodies (ANCA) play an important role in the patho
physiology of Churg Strauss syndrome, microscopic polyangiitis, Wegener’s granulomatosis and related
forms of vasculitis. Rituximab is a monoclonal antibody against the CD 20 antigen on B – lymphocytes
and activates complement dependent B-cell cytotoxicity.
CASE PRESENTATION: A 54 year old female with a past medical history of anemia, recurrent sinus
congestion, and gastro esophageal reflux disease presented with generalized weakness and fatigue,
associated with nausea, vomiting, decreased oral intake, acute kidney injury with increasing Creatinine
levels. Rheumatology workup revealed positive CANCA. Patient was immediately started on high dose
steroids and azathioprine. Azathioprine was discontinued because of worsening renal failure and
cyclophosphamide was started. The patient showed symptomatic improvement and was discharged.
However, she was readmitted because of recurrent anemia and worsening renal function, with
increasing Creatinine levels. Cyclophosphamide was discontinued, and she was started on Rituximab.
The patient improved symptomatically with fewer side effects, did not develop any complications and
has been following up with her primary care physician and rheumatologist for the last seven months and
is currently doing well.
DISCUSSION: Two prospective randomized controlled trials published in May 2011 have shown that
Rituximab can be used in induction therapy in active ANCA associated vasculitis. The safety profile of
Rituximab is favorable when compared to steroids and cyclophosphamide. According to a randomized
controlled trial published in 2010, Rituximab based regimen was not superior to standard
cyclophosphamide therapy for severe ANCA associated vasculitis.
Rituximab may represent a promising new drug for treatment of patients with ANCA-associated
vasculitis in whom either standard therapy has failed or contraindicated. On April 19, 2011 the FDA
approved Rituximab (Rituxan) combined with glucocorticoids for the treatment of adult patients with
granulomatosis with polyangiitis (GPA; Wegener’s granulomatosis) or microscopic polyangiitis
(MPA). More research is warranted to determine the overall efficacy of the drug.
324

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Jessie Roske, MD
Severe Encephalopathy and Impending Cerebral Herniation in Acetaminophen Toxicity: Recovery with a
Novel Hypernatremic/Hypothermic Protocol
Jessie L. K. Roske, MD Second Author: William T. Browne, MD
INTRODUCTION: Acute liver failure affects approximately 2000 persons in the U.S. each year; 39% of
these cases are related to acetaminophen overdose. Survival rates for ALF without transplantation range
from 17-68%, although acetaminophen overdose has the lowest mortality rate. A substantial number of
patients die waiting for liver transplantation and another segment of the patient population is never
listed. As a transplant center, the challenging clinical situation of acetaminophen-induced acute liver
failure in patients deemed not to be transplant candidates is encountered all too often. For those
ineligible for or awaiting transplantation, care focuses on supportive care in an extremely complex
critical illness that can rapidly devolve. Causes of death include cerebral edema, multi-organ failure,
sepsis, cardiac arrest, and respiratory failure. Efforts to improve survival are as essential as they are
challenging in this life-threatening multi-system disease process.
CASE PRESENTATION: A 37-year-old female with a past medical history significant for alcohol
dependence presented with encephalopathy, coagulopathy and hyperbilirubinemia and was found to
have a toxic acetaminophen level 48 hours after ingestion. Given refractory alcoholism with multiple
failed courses of substance abuse treatment, the patient was considered not a candidate for liver
transplantation. The patient’s neurologic status deteriorated with evidence of impending central
herniation including extensor posturing, sustained clonus and bilateral Babinski sign. In an effort to
avoid catastrophic neurologic sequelae, hypernatremia to 165mmol/L and hypothermia to 32°C were
urgently induced. Additional complications during the ICU stay included acute anuric renal failure
requiring renal replacement therapy and further derangement in liver function tests with undetectably
elevated INR. Given markedly elevated INR, placement of ICP monitor was felt to be contraindicated.
Continuous renal replacement therapy was utilized for maintenance of hypernatremia. Ultimately, in the
absence of direct ICP measurement, the patient was cooled for a total of 6 days, with timing of
rewarming based on improving neurologic exam, corresponding improvement in liver function, and
serial head CT scans. The patient was subsequently extubated and discharged on hospital day 32 with
complete neurologic recovery and improving hepatic function.
DISCUSSION: In review of the literature, the methods employed in this case are described individually
but to our knowledge no similar protocol has been previously presented with case experience. In this
very challenging case, the efforts of a multidisciplinary team to extrapolate clinical experience and
limited published literature to develop a novel induced hypernatremia/hypothermia protocol produced
an extremely satisfactory outcome.
325

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Muaz M Abudiab, MD
All That Is Myxoma Does Not Plop: An Interesting Presentation Of Left Atrial Mass
Muaz M. Abudiab, MD* Other Authors: Olufunso W. Odunukan, MBBS*, Daniel K. Chan, MD*, Rowlens
M. Melduni, MD§ *Department of Internal Medicine, Mayo Clinic, Rochester, MN §Division of
Cardiovascular Diseases, Mayo Clinic, Rochester, MN
INTRODUCTION: Cardiac tumors may remain asymptomatic until incidental discovery or present with
various signs including those of systemic embolization. They must therefore be considered in the
evaluation for a cardiogenic etiology of neurologic deficits.
CASE PRESENTATION: A 46-year-old female with major depressive disorder and tobacco abuse
presented to her local emergency department with sudden onset right arm and hand weakness. Five
months prior she had started estrogen replacement therapy following gynecologic surgery for benign
reasons. She noted difficulty lifting her right arm to smoke a cigarette earlier that morning but
nonetheless accompanied her husband to his doctor’s appointment. However, she became concerned
while leafing through a stroke pamphlet and decided to seek evaluation. On arrival to the ED, symptoms
had been present for six hours. Physical exam demonstrated significant weakness of the right upper
extremity distal to the shoulder. Cardiac exam was unremarkable. Electrocardiogram displayed normal
sinus rhythm, and a non-contrast CT scan of the head was negative. She was admitted to the Neurology
service where, three days later, she underwent MRI of the head due to persistent deficits. This
demonstrated multifocal punctate acute lacunar infarcts throughout the left temporal, parietal,
occipital, and frontal lobes as well as the left caudate head and left basal ganglia. These findings were
felt to be highly suggestive of proximal embolic phenomena. Transthoracic echocardiogram (TEE)
showed a 2.2 x 1.0 cm serpiginous appearing mobile left atrial mass attached to the junction of the atrial
septum and posterior left atrial wall. Given concern for thrombus, Cardiology advised starting IV
heparin. Further studies including serum and urine protein electrophoresis and hypercoagulable workup
were unremarkable. Holter monitoring was negative for arrhythmia. A cardiac MRI was obtained to
further define the lesion but visualized no intracardiac mass or thrombus. By day five of hospitalization
the patient’s neurologic exam had normalized. Repeat TEE demonstrated a 6.0 x 6.0 mm sessile left
atrial mass. Three days later the patient underwent excision of a 1.0 x 1.0 cm left atrial myxoma via
biatrial approach. Follow-up TEE was reassuring, and she was dismissed from the hospital. Her postoperative
course was complicated by atrial fibrillation requiring TEE-guided cardioversion.
DISCUSSION: While the majority of presenting symptoms of atrial myxoma are cardiovascular, nearly
twenty percent of patients have neurologic deficits due to embolization of tumor fragments or thrombi.
Differentiation between tumor and thrombus can be difficult by noninvasive imaging techniques.
However, once a presumptive diagnosis of myxoma is made, prompt resection is required.
326

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Elena N Kazimirko, MD
An unusual complication of a routine abdominal work-out
Elena N Kazimirko, MD; Christopher Wittich, MD
INTRODUCTION:Spontaneous rectus sheath hematoma arises from rupture of epigastric vessels and
usually presents in setting of trauma, or anti-coagulation. It is a relatively rare disorder in the clinical
setting, and often difficult to distinguish from other abdominal pathologies, and therefore is often
misdiagnosed.
CASE PRESENTATION: A 59 year old female with a past medical history significant for chronic kidney
disease due to autosomal dominant polycystic kidney disease, living related donor transplant in January
of 2009, presented for evaluation of acute abdominal pain. The patient was in her usual state of health
until the day of presentation. She had done upper body and abdominal exercises and crunches in the
morning and around 11 am developed a sudden sharp, “spasm”-like pain located supra-pubically with
right sided-predominance. She described a progression in severity of pain until arrival to the Emergency
Department around 2 p.m. She was also experiencing nausea with one episode of non-bilious, nonbloody
emesis that occurred in the emergency department. The patient denied any fevers, back pain,
hematuria, urinary burning or frequency. Patient’s medications included aspirin 81 mg, antihypertensives
and immunosuppressive therapy. Physical examination showed a female that appeared to
be well-nourished, well appearing, slightly drowsy with normal heart and lung examination. Abdominal
examination revealed no evidence of ecchymoses, normal bowel sounds, and moderate to severe
tenderness and voluntary guarding over RLQ and supra-pubically, with fullness on palpation. Further
mass was in left pelvic area consistent with patient’s transplanted kidney. No rebound tenderness was
found and Carnett’s sign was found to be positive. The patient’s blood work revealed a normal CBC with
differential, electrolyte panel consistent with patient’s chronic kidney disease as well as normal liver
function tests. The patient required significant opioid medication for pain control. CT scan of the
abdomen was pursued and revealed 4.6 *8.4 *12.3 cm right rectus sheath hematoma. The patient was
admitted to a general medicine service to monitor for evidence of further bleeding. The patient’s
showed blood loss on Hemoglobin monitoring, with lowest Hemoglobin of 11.1 g/dL (baseline 13.2).
Prothrombin time and activated partial thromboplastin time were found to be within normal limits. The
patient’s vital signs remained stable, plateau of anemia reached, and ecchymosis became evident over
the right lower abdomen. The patient was discharged home with weight bearing and physical activity
limitations. On follow up, the patient had no further complications.
DISCUSSION: Rectus sheath hematoma should be considered in previously asymptomatic individuals
with acute onset abdominal pain, localized to rectus sheath with a positive Carnett’s sign and a palpable
mass. The physical exam maneuver, known as Carnett’s sign can be a diagnostic. Early diagnosis may
avoid unnecessary testing or invasive procedures.
327

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Mary C Drinane, MBChB
Dermatomyositis: A Diagnosis Not Easy to Swallow
Mary C Drinane, MBChB Second Author: Anna Svatikova, MD Third Author: John Schoolmeester, MD
Last Author: William Ward, MD
INTRODUCTION: Dermatomyositis is an inflammatory myositis classically presenting in middle-aged
patients with an insidious proximal muscle weakness and characteristic skin findings. Dysphagia is a
known complication of inflammatory myositis and can be the presenting symptom prior to clinically
evident myopathy or biochemical evidence of myositis. This case highlights that inflammatory myositis is
an important consideration in patients with idiopathic dysphagia.
CASE PRESENTATION: An 84 year old woman presented with progressive dysphagia over one week.
Difficulty swallowing began with solids only, and soon included liquids and episodes of nasopharyngeal
regurgitation. She had no other neurological symptoms or neurologic exam findings at time of
presentation. She had a heliotrope rash around both eyes and Gottron's sign over her MCP joints. CT
brain was negative for hemorrhage, mass, or acute ischemia. Swallow study showed pooling in the
vallecula with penetration of the trachea and weak cough. She had an elevated CK (346 U/L), aldolase
(11 U/L), and AST (64 U/L). ANA was positive with a weakly positive SCL-70 and antimitochondrial
antibody. EMG showed evidence of a mild proximal myopathy involving upper limbs greater than lower
limbs, without compelling evidence of accompanying fiber splitting, vacuolation or necrosis. Shave
biopsy of a papule on her left 3 rd MCP showed interface vacuolar dermatitis and stained positive for
ANA, IgG, and IgM, consistent with dermatomyositis. Investigations for underlying malignancy including
EGD, colonoscopy, and CT chest, abdomen, and pelvis were negative. She was treated with 30 mg of
prednisone daily and a five day course of IV immunoglobin. After three weeks of treatment, her
symptoms were improved, and a repeat swallow study showed improvement in her swallow with
penetration to the vocal cords only with thin consistency.
DISCUSSION: Dysphagia is a recognized complication of inflammatory myositis. It usually manifests
with pharyngeal regurgitation, due to weakening of oropharyngeal muscles and striated muscle in the
upper one third of the esophagus. Esophageal involvement eventually develops in over one third of
elderly patients with dermatomyositis. However, there is no published description of dysphagia as the
presenting symptom of dermatomyositis, as it was in this case. Of inflammatory myositis subtypes,
inclusion body myositis presents most frequently with dysphagia, in 21-69% of cases. Treatments
include immunosuppression of the underlying myositis, myotomy, dilation, or Botox injection. Physical
therapy has also been used, but its efficacy is not well established. Malignancy has been noted to occur
in 47.8% of elderly patients with dermatomyositis compared to 9.1% in patients under the age of 65. In
patients with dermatomyositis, dysphagia is associated with poor prognosis, a 31% 1 year mortality.
328

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Evan L Hardegree, MD
A Woman With Blurred Vision Who Didn’t Know 'HACEK' She Was
Evan L Hardegree, MD, Shaina A Rozell, MD, MPH, Walter R Wilson, MD
INTRODUCTION:Infective endocarditis (IE) may present with myriad embolic phenomena affecting
seemingly disparate organ systems, potentially leading to delayed diagnosis. Thus in high-risk patients,
such as those with congenital heart disease or prosthetic heart valves, there should be a low threshold
to investigate for IE.
CASE PRESENTATION: A 40-year-old woman presented after one week of fevers, left eye irritation and
blurred vision. Systems review revealed new exposure to cats for the previous 3 weeks. Her history
included congenitally-corrected transposition of the great arteries and implantation of a mechanical
tricuspid valve at age 13. Physical examination was notable only for crisp mechanical heart sounds and
left periorbital erythema with scleral injection. Retinal examination revealed vitreous opacities and
retinitis. Given her feline exposure, she was treated empirically for ocular toxoplasmosis with
trimethoprim/sulfamethoxazole and steroid eye drops. Toxoplasma serology and blood cultures were
drawn, and aqueous humor was aspirated and sent for cultures and toxoplasma testing.
Five days later, she was seen in Ophthalmology with worsening vision and intermittent fevers.
Toxoplasma serologies, blood cultures, and ocular microbiologic testing returned negative. The following
day, one of six blood culture bottles returned positive for Haemophilus aphrophilus. This raised concern
for IE with secondary endophthalmitis. She underwent transesophageal echocardiography, revealing a 5
x 10mm subvalvular vegetation consistent with IE. Thus she was admitted for initiation of intravenous
ceftriaxone. Ophthalmology diagnosed her with bacterial endophthalmitis and performed vitrectomy
with intravitreous injection of ceftriaxone, vancomycin, and clindamycin.
Unfortunately, the patient’s left eye vision did not fully recover. Nonetheless, she defervesced, her
blood cultures became negative, and she was dismissed from the hospital to complete a six-week course
of ceftriaxone.
DISCUSSION: While most cases of prosthetic valve IE are due to Staphylococci, Streptococci, and
Enterococci, the HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and
Kingella) are fastidious, gram-negative organisms which cause 5 to 10% of cases.
Our patient’s congenital heart disease and prosthetic valve predisposed her to IE. The organism was
Haemophilus aphrophilus, which may also cause orthopedic infections, meningitis, brain abscess, and
empyema. As this organism grows slowly, patients often present subacutely after long periods of
bacteremia, allowing formation of large vegetations and subsequent embolization. Interestingly,
concurrent IE and endophthalmitis due to H. aphrophilus has not previously been reported.
Treatment of HACEK prosthetic valve IE consists of 6 weeks of intravenous therapy with a 3 rd - or
4 th -generation cephalosporin, ampicillin-sulbactam, or ciprofloxacin. Bacterial endophthalmitis is treated
with surgical vitrectomy and intravitreous antibiotics. Prognosis is fair with HACEK group IE, with an
estimated mortality of 10-15%. Visual outcomes following endophthalmitis are difficult to predict,
with slow recovery taking place over several months as intraocular inflammation resolves.
329

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Livia L Hegerova, MD
Wives Know Best
Livia L Hegerova, MD
INTRODUCTION: It is estimated that up to 50% of patients with brain lesions have psychiatric
manifestations. Specifically, frontal lobe lesions are associated with nearly 90% of these psychiatric
symptoms. The specific psychiatric symptoms are dependent on the location within the brain and
amount of mass effect or direct invasion.
CASE PRESENTATION: A 65 year old man with a history of prostate cancer was admitted with
complaints of a three day history of leg weakness and loss of peri-rectal sensation. He was originally
diagnosed with Stage IV prostate cancer six months earlier. At that time, he presented with an elevated
PSA, multiple painful bony, and spinal epidural metastases. He was receiving hormonal treatment with
Lupron. At the time of this hospitalization, MRI thoracic and lumbar spine revealed progressive
metastatic disease from L4 through T4. Due to these findings, he was started on a course of steroids
and spinal radiation.
While undergoing treatment for spinal cord compression, it was noted that the patient was acting
bizarre. His behavior was uninhibited, including use of profane language and wearing inappropriately
little clothing. His wife reported this behavior was new and requested imaging of his brain. She felt her
husband had been acting unusual with frequent irritable outbursts and occasionally slurring words.
Due to this altered mental status a brain MRI was performed which revealed a single dural metastases
overlying the left frontal lobe. This mass was noted to result in mass effect and small left frontoparietal
subdural effusion. Due to the presence of psychiatric abnormalities, treatment was initiated with IV
dexamethasone. stereotactic gamma knife, and docetaxel.
DISCUSSION: The link between the frontal lobes and emotion draws back to the 1800s with the case of
Phineas Gage. Changes in personality, intellect, uncoordinated walking, loss of smell, and speech
difficulties are encountered with frontal lobe tumors. Prostate and breast cancers typically lead to dural
brain metastases. In contrast, parenchymal brain metastases occur most commonly with lung, breast
and renal cancer. The case is a reminder that a seemingly difficult patient may carry more than a bad
attitude and family may be the key to identify subtle personality changes.
330

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Shiao Yen Khoo, MD
Recurrent Unexplained Ascites: A Harbinger of Evil
Shiao Yen Khoo, MD Second Author: Jason Post, MD
INTRODUCTION:Recurrent ascites of unknown etiology is an uncommon occurrence and could be an
indicator of peritoneal carcinomatosis.
CASE PRESENTATION: We report a case of a 52-year-old man with cold agglutinin syndrome and
antiphospholipid antibody syndrome maintained on anticoagulation and chronic immunosuppressant
therapy who presented with 5 months of recurrent ascites associated with partial small bowel
obstructions and an unintentional 30 pound weight loss in 6 months. Prior investigations included 3
diagnostic and therapeutic paracentesis amounting to 9 liters with serum ascites albumin gradients > 1.1
g/dL, total ascitic protein > 1 gm/dL and negative cytology repeatedly. On presentation, his vital signs
were normal and physical examination was remarkable only for ascites. A fourth paracentesis was done
and was significant for 1068 white blood cells/mm3, with 1% neutrophils and 15% lymphocytes. Ascitic
fluid to ascites LDH ratio was < 1.0. Extensive work-up included a normal transthoracic echocardiogram;
abdominal ultrasound that showed patent portal vessels; FNA of the liver with normal tissue on
pathology; mildly positive ANA, but negative ENA; and negative infectious work-up including negative
ascitic fluid cultures, ascitic fluid mycobacterial PCR, fungal serologies, hepatitis screen, HIV and blood
cultures. PET/CT revealed only minimal diffuse peritoneal FDG uptake indicative of peritonitis. He
underwent explorative laparoscopy, which was evident for peritoneal carcinomatosis with malignant
adhesions requiring extensive adhesiolysis, laparotomy and creation of a diverting loop ileostomy.
Pathology was consistent with a poorly differentiated adenocarcinoma with an unknown primary. He
deteriorated clinically soon after, suffering from multi-organ failure. He was transitioned to comfort
cares only on hospital day 26 at the request of his family and passed away peacefully on hospital day 35.
Final autopsy report revealed primary appendiceal adenocarcinoma with peritoneal carcinomatosis.
DISCUSSION: Recurrent ascites of unknown etiology is uncommon and could be an indicator of
malignancy-related ascites especially in the setting of weight loss. Ascitic fluid analysis is key in
establishing the diagnosis; however, the overall sensitivity of cytology smears is 58-75% depending on
the processing quality. Peritoneal carcinomatosis accounts for approximately two-thirds of patients with
malignancy-related ascites. When large volume paracentesis is non-diagnostic, an open laparotomy with
omental biopsies can be helpful in diagnosing peritoneal carcinomatosis.
331

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Ammar M Killu, MBBS
Hypopyon: More than Meets the Eye.
Ammar M Killu, MBBS Miguel Lalama, MD Christopher Janish, MD Syed Ahsan Rizvi, MD
INTRODUCTION: Background
Endogenous bacterial endophthalmitis (EBE), a rare condition, results from the spread of pathogens
from a remote focus and is an ocular emergency requiring urgent treatment to prevent significant visual
loss. EBE carries a poor prognosis with bilateral involvement in 25%. 78% and 29% are left with
maximum 20/400 vision or enucleation/evisceration, respectively. The main prognostic factors are
pathogen virulence, host-immunity and time to diagnosis. Two-thirds of cases have predisposing factors
(diabetes mellitus, valvular heart disease, recent surgery, IV drug abuse, immunosuppression). The
commonest source in the U.S. is endocarditis.
CASE PRESENTATION: A 62-year-old woman with poorly controlled type-2 diabetes mellitus and
chronic kidney disease sought medical attention for acute visual change. She developed isolated low
back and left hip pain two weeks earlier. Four days prior to presentation, she developed right eye
teichopsia. An optometrist diagnosed anterior uveitis; tobramycin, prednisone and cyclopentolate were
prescribed. Later, she developed photophobia and deep right eye pain with complete blindness the day
of presentation. There was no history of trauma or glaucoma. She reported progressive left knee pain.
On examination, vital signs were normal. Musculoskeletal examination revealed left knee erythema,
swelling, and pain with passive and active movement, L3-4 spinal tenderness and left ankle Charcot’s
joint. Right eye examination revealed 2.6mm hypopyon, conjunctival injection temporally with
subconjunctival hemorrhage inferiorly, no light perception, anterior chamber cells and flare with retinal
detachment and raised intraocular pressure. Laboratory testing showed Hb 8.2g/dL, WCC 27.2x10(9)/L,
creatinine 2.3mg/dL, BUN 79mg/dL, ESR 44mm/hour.
Based on examination findings, rapid progression, leucocytosis and immunosuppression, endogenous
endophthalmitis was diagnosed. Blood cultures were obtained. She was commenced on systemic
parenteral and intraocular antibiotic therapy with vancomycin, ceftazidime and
fluconazole. Investigation to identify the source revealed left iliopsoas abscess with L3/L4 vertebral
body osteomyelitis. Transesophageal echocardiogram was negative for endocarditis.
DISCUSSION: In contrast to exogenous endophthalmitis, systemic cultures are needed in addition to
vitreal samples for EBE. However, while ocular cultures are less often positive, they may be the only
source of growth. Streptococcus species and Staphylococcus aureus are the commonest pathogens, the
latter commonly resulting in bilateral endophthalmitis.The cornerstone of management is intravitreal
antibiotics, vitrectomy and early systemic antibiotic therapy (preventing continued bacteremia,
protecting the unaffected eye). Topical corticosteroids and cycloplegia play a role, preventing
inflammatory ocular sequelae. 50% of EBE have no systemic symptoms frequently leading to
misdiagnosis, as uveitis. As our case exemplifies, prompt recognition, management and referral to
ophthalmology by the internist is critical in avoiding devastating consequences. Endogenous
endophthalmitis should be considered in any patient complaining of decreased vision or eye pain in the
setting of possible bacteremia.
332

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Yoel Korenfeld, MD
A Whole Hearted Welcome To The United States - Health Globalization And Resurgence Of Eisenmenger
Syndrome
Yoel Korenfeld, MD
INTRODUCTION: Eisenmenger Syndrome (ES) is a complication of congenital heart disease with
reversed shunting secondary to severe pulmonary hypertension. Most patients with ES survive to
adulthood and require management of this multisystem disease. We present a newly diagnosed case of
a woman from Macedonia who moved to the United States 2 months prior to presenting with syncope
secondary to ES as a complication of a large atrial septal defect.
CASE PRESENTATION: The patient is a 26 year old woman who moved to the US from Macedonia 2
months prior to presenting with syncope to a suburban ED. She had been having dyspnea on exertion
and lightheadedness for 1 month. Before these symptoms started she was healthy and was not taking
any medications. She used to play sports in high school without any symptoms. On physical exam her
blood pressure was mildly elevated at 135/95 mmHg. Heart rate was 62, respiratory rate was 16, and
temperature was 98.5ºF. Her pulse oximetry was low at 82%. Her body mass index was 37 kg/m2. She
was in no respiratory distress. She was noted to be diffusely cyanotic. Her lungs had diffuse bilateral
crackles in the bases. Cardiac exam revealed a very loud pulmonary component of the second heart
sound but no murmur was heard. Abdomen was obese with diffuse tenderness; no hepatomegaly was
observed. She had clubbing of fingers and toes. Pulses were equal and symmetric in four extremities.
Laboratories showed hemoglobin 24.1 g/dL and hematocrit 74.6%. Uric acid was 12.6 mg/dL and iron
deficiency was confirmed. An electrocardiogram showed biatrial enlargement, QRS right axis deviation
and right ventricular hypertrophy. Both an echocardiogram and MRI showed a large 16 mm atrial septal
defect with right to left shunt. A right heart catheterization showed pulmonary pressure 140/74 mmHg
and pulmonary vascular resistance 24 Wood units. These values did not change with nitric oxide.
Phlebotomy improved hyperviscosity symptoms. The patient developed gout. She was started on
tadalafil and oxygen at night. A month after presentation her symptoms were dramatically improved.
Oral contraception was started.
DISCUSSION: An increase in immigration from developing areas will likely increase the incidence of ES
in industrialized countries. We present a case of ES secondary to atrial septal defect that was never
diagnosed in childhood. This patient presented with all the associated multisystem effects of ES. It is
important that internists are familiar with ES and its management as more patients with ES will likely
present to our clinics in the near future.
333

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Nicole M Loo, MD
A Rare Case of Native Aortic Valve Pseudomonas Endocarditis
Nicole M Loo, MD Second Author: Roger L. Click, MD Third Author: Barry L. Karon, MD
INTRODUCTION: CASE PRESENTATION: A 47 year-old Caucasian male with autosomal dominant
polycystic kidney disease complicated by end-stage renal disease on hemodialysis via fistula was
undergoing routine evaluation for renal transplant. He reported new exertional dyspnea and a
dobutamine stress echocardiogram revealed native aortic valve thickening, possible vegetations, and
severe aortic regurgitation. He was admitted to the hospital for presumed native aortic valve infective
endocarditis.
Two months prior he had new onset fevers and painful left testicular edema, and was hospitalized at an
outside facility for epididymitis with pan-sensitive Pseudomonas aeruginosa bacteremia. This was
treated with IV antibiotics plus 4 weeks of oral levofloxacin. He initially improved, but within a week of
finishing his antibiotic course, he had recurrence of his symptoms. Repeat blood cultures again showed
pan-sensitive Pseudomonas aeruginosa. A 2 week course of oral levofloxacin followed by a 3 week
course of oral ciprofloxacin was prescribed (the change was due to medication costs). This treatment
resolved his fevers and testicular swelling, and he had just finished the antibiotic course prior to the
renal transplant evaluation visit.
Transesophageal echocardiogram at admission confirmed a flail aortic valve leaflet with severe aortic
regurgitation, mobile aortic valve echodensities >10 mm, and no perivalvular spread of
infection. Empiric antibiotics were held as he remained afebrile, hemodynamically stable, and did not
demonstrate leukocytosis, bacteremia, or urinary tract infection. Testicular and transrectal ultrasound
revealed fluid collections in his left epididymis region (2.5 x 3 x 2.5 cm) and prostate. The prostate fluid
collection was small in the setting of a normal PSA. Urology recommended conservative management
and oral ciprofloxacin was restarted.
By hospital day #4-5, one blood culture set grew quinolone-resistant Pseudomonas aeruginosa at 32.66
hours. Infectious Diseases recommended dual therapy with IV meropenem and tobramycin in addition
to aspiration of his prostate fluid collection. Prostatic fluid was gram stain and culture negative. After
much discussion amongst Cardiovascular Surgery, Urology, and Infectious Diseases, a prophylactic left
orchiectomy was performed to aid bacteremia clearance, a priority in the setting of incipient aortic valve
replacement. He remained stable during an additional 6 weeks of antibiotics and then underwent aortic
valve replacement. Unfortunately, he was found to have culture positive Pseudomonas annular abscess
near the right cusp of the aortic valve during surgery and required another 6 week course of antibiotics.
DISCUSSION: Pseudomonas aeruginosa endocarditis is rare, usually occurring in IV drug users with
prosthetic valve or tricuspid valve involvement. In this case, native aortic valve Pseudomonas
endocarditis due to epididymitis is reported, with no evidence based medicine or case series to guide
decision-making regarding prophylactic orchiectomy for bacteremia clearance.
334

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Jasmine R Marcelin, MD
HSV viremia & hepatitis presenting as febrile neutropenia
Jasmine R Marcelin, MD Jason M Jones, M.D., Brian A. Costello, M.D.
INTRODUCTION: INTRODUCTION: Acute liver failure is often serious and can be a life-threatening
condition. It is characterized by the rapid onset of structural liver injury (manifested by sudden rise in
liver enzymes) and acute functional injury (manifested by decreased protein metabolism) leading to
encephalopathy. The challenge to physicians is to recognize early structural injury, intervening
successfully before function begins to decline.
CASE PRESENTATION: Case Description: A 41 year old female with a history of stage 1 invasive ductal
carcinoma of the breast underwent wide local excision. Oncotype Dx testing revealed high recurrence
score and therefore, she received adjuvant chemotherapy with docetaxel and cyclophosphamide. She
presented 4 days after her second cycle of chemotherapy with febrile neutropenia and a sore
throat. The patient was admitted to the hospital, pan-cultured and started on intravenous antibiotics.
Physical exam revealed fever, tachycardia, tachypnea, and clear lung fields. Chest X-ray, rapid strep
test, blood and urine cultures were negative. Despite treatment with cefepime, vancomycin,
levofloxacin and metronidazole, the patient remained febrile with fevers occurring in a cyclic pattern. In
addition, the patient developed aphthous ulcers as well as a plaque-like lesion concerning for fungal
infection and caspofungin was initiated. Ultimately, the patient developed right upper quadrant pain,
and AST and ALT were found to be rising. These peaked at 1701 and 871, respectively. Caspofungin was
discontinued and Hepatitis A, B, and C, CMV, EBV, and parvovirus screening was negative. Serum HSV 1
PCR and swab of the oral ulcers for HSV were positive. Antibiotics were discontinued and the patient
was started on IV acyclovir. The patient’s fever, right upper quadrant pain and transaminases improved
over the first 48 hours. The patient was discharged on 4 weeks total acyclovir with complete resolution
of her symptoms and normalizing transaminases.
DISCUSSION: DISCUSSION: Liver transaminases elevated to the thousands typically generate a
differential diagnosis of acetaminophen toxicity, hepatitis virus infection or ischemic liver disease. Nonhepatitis
viruses are less common but must also be considered, especially in an immunocompromised
patient, in whom HSV viremia can be rapidly fatal. In this case, correlation of the mouth ulcers and acute
hepatitis with the laboratory finding of viremia prompted initiation of acyclovir and reversed the
impending liver failure. However, diagnosis was delayed until these physical signs became evident. This
case underscores the value of a thorough history and physical in combination with a broad differential in
the diagnosis of acute liver failure. In addition, this case highlights the value in testing for other viral
causes of liver failure, including HSV, EBV, parvovirus and CMV, in immunocompromised patients.
335

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Eric M Nelsen, MD
Yersinia Enterocolitis Presenting As Acute Cholecystitis
Eric M Nelsen, MD Second author: Madhusudan Grover, MD Third author: Amindra S. Arora, MD
INTRODUCTION: Yersinia Enterocolitica is known to cause infectious ileocolitis. It can present with
severe abdominal pain often mimicking acute appendicitis. We present an unusual case of Yersinia
Enterocolitica mimicking acute cholecystitis.
CASE PRESENTATION: A 27 year old female with history of irritable bowel syndrome presented with
eight days of severe abdominal pain and diarrhea. The diarrhea was described as having 8-10 watery,
non-bloody, non-mucous bowel movements. She also had a fever of 102 degrees F with reported
chills. The abdominal pain was across her upper abdomen. She did report some nausea, but no
vomiting. She had no sick contacts. Given her history, stool was sent for polymerase chain reaction
(PCR) of enteric pathogens and CT abdomen was obtained. CT demonstrated marked edematous
changes within the wall of the gallbladder and edematous changes within the terminal ileum and right
colon. Laboratory testing revealed an AST of 81 U/L (normal: 8-48), ALT of 125 U/L (normal: 7-55) and
Alkaline Phosphatase of 228 U/L (normal: 24-336).
The patient was admitted to the hospital for further management. An abdominal ultrasound was done
that showed diffuse marked gallbladder wall thickening measuring 13 mm. The gallbladder lumen was
contracted; no cholelithiasis or pericholecystic fluid was present. Patient had a negative sonographic
Murphy's sign. Surgery was consulted for consideration of cholecystectomy for acute acalculous
cholecystitis. However, on hospital day 2 her stool studies revealed positive PCR Yersinia
Enterocolitica. She was started on levofloxacin and metronidazole. Her abdominal pain and diarrhea
improved and she was discharged on hospital day 4. She was continued on levofloxacin for a total of 14
days. Follow-up abdominal ultrasound at two weeks showed complete resolution of the gallbladder wall
thickening; the gallbladder wall measured 1.6 mm, decreased from 13 mm on prior US. She had
complete resolution of abdominal pain and diarrhea.
DISCUSSION: Yersinia Enterocolitica is classically known to cause ileocolitis, often mimicking Crohn’s
disease or acute appendicitis. However, acute cholecystitis in the setting of acute ileocolitis, should alert
to possible infectious etiologies such as Yersinia enterocolitis. Stool PCR might offer higher sensitivity
and have a faster turn around in the work-up for acute ileocolitis compared to stool cultures.
336

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Darrell B Newman, MD
Potential association of pathogenicity with a previously reported low-density lipoprotein receptor
polymorphism in individuals of African descent
Darrell B Newman, MD Second Author: Suraj Kapa, MD Third Author: Gautam Kumar, MBBS Fourth
Author: Richard M Elias, MBBS
INTRODUCTION: Several hundred low density lipoprotein receptor (LDLR) mutations have been
identified and characterized in specific populations (2). We present a case of premature acute coronary
syndrome of in a patient of African descent involving a rare mutation in the EGF-like calcium binding
domain of the LDLR that, to our knowledge, has not previously been associated with pathogenicity.
CASE PRESENTATION: A 23-year-old Somali male with no significant past medical history presented to
an outside hospital with severe, substernal chest pain of 2 hours duration. An EKG at that time showed
2-3 mm ST elevation in leads II, III, and aVF. Laboratory studies were remarkable for a Troponin T of 2.79
ng/mL (normal < 0.03 ng/mL). He was immediately transferred to our hospital by ground ambulance
where he underwent percutaneous coronary intervention (PCI) of a ST-elevation myocardial infarction
(STEMI). Cardiac catheterization revealed complete occlusion of the proximal right coronary artery and,
following revascularization, he underwent successful deployment of a drug-eluting stent in the right
coronary artery. Subsequent laboratory analysis revealed a total cholesterol of 278 mg/dL (normal < 200
mg/dL) , LDL of 226 mg/dL (normal < 100 mg/dL), and HDL of 39 mg/dL (normal range > 40 mg/dL).
Homocysteine, Lipoprotein (a), and high sensitivity C-reactive protein levels were within established cutoff
values. The patient did not use nicotine or ethanol. On physical exam, there were no outward signs
of hypercholesterolemia. On further review, he was unaware of any history of cardiac events in the
immediate family.
Genetic testing revealed a variant of likely pathogenicity at Exon 8, Nucleotide 1145 (1145G>T) of the
LDLR resulting in a missense mutation (G382V) in the EGF-like 2 potential calcium-binding
domain. There is a moderate stereochemical difference between Glycine and Valine and this mutation
should not be tolerated according to Poly Phen or SIFT prediction models (3, 4). The results of MLPA did
not reveal a large genomic deletion or duplication in the LDLR gene, further supporting a disease-causing
role of the identified mutation. APOB genotyping was not performed given the African ethnicity of this
patient.
DISCUSSION: The novel mutation described herein is potentially pathogenic and thus, may be
consistent with a diagnosis of familial hypercholesterolemia. This variant has not previously been
reported as a known deleterious mutation in publicly available gene compendiums. Therefore, we
believe this to be a novel, potentially pathogenic mutation in the LDLR gene and recommend that
screening, in particular of patients of African-descent, should include notation of this specific variant.
337

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Sandeep M Patel, MD
A Diagnosis Caught "Red-Handed"
Sandeep M. Patel, MD, Katie M. Rieck, MD, Aurelia A. Smith, MD, Raghuwansh P. Sah, MD, M. Caroline
Burton, MD
INTRODUCTION: Dermatologic manifestations may be the first sign of an underlying systemic
disorder. However, if the “rash” is not obvious, a massive work-up may ensue delaying therapeutic
intervention. We present an interesting case of “red hands” that ultimately guided us towards the
correct diagnosis.
CASE PRESENTATION: A 74-year-old male without past history presented for second evaluation of
hand pain. The pain began 2 months ago and was gradual in onset. He described the pain as “being on
fire” involving mainly the palms of both hands. He revealed that the pain improved with elevation and
ice but worsened when his hands were at his sides. Concomitantly, he noted that his hands were more
reddish-purple in color. On review of systems, the patient noted fatigue and occasional night sweats.
Notable exam findings included a cachectic-looking Caucasian male in no distress. Abdominal
distension was noted with dullness to percussion 6 cm below the right costal margin and a palpable
spleen tip 4 cm to the left of the umbilicus. Dermatologic exam demonstrated erythematousviolaceous,
diffusely tender palms that were warm to touch with slight moistness. With elevation above
his head, there was improvement of the pain and central pallor of his palms within 30 seconds; with
dependency the initial findings returned. Radial and ulnar pulses were intact bilaterally. The rest of the
exam was unremarkable.
At our institution, initial complete blood count with differential was notable for WBC 18.0 x 10(9)/L (83
% Neutrophils, Lymphocytes 7%, Monocytes 1%, Eosinophils 1%, Basophils 5%, Metamyelocytes 2%,
Myelocytes 2%), Hemoglobin 13.5 g/dL, Platelets 309 x 10(9) g/dL, and normal electrolytes and liver
function. A peripheral smear demonstrated toxic changes and Dohle bodies. Erythrocyte sedimentation
rate and c-reactive protein were minimally elevated. Serum and urine protein electrophoresis with
immunofixation were unremarkable. Anti-nuclear and anti-neutrophilic cytoplasmic antibodies were
negative. Computed tomography of the abdomen demonstrated hepatosplenomegaly without
ascites. Review of an outside bone marrow biopsy demonstrated no notable findings.
The dermatologic changes were consistent with erythromelalgia. Given the constellation of findings, a
hematologic disorder was suspected. The patient underwent a second bone marrow biopsy which
demonstrated a myeloproliferative neoplasm consistent with primary myelofibrosis with JAK 2 V617F
positivity. The patient was initiated on aspirin and is currently undergoing evaluation for trials involving
JAK 2 inhibitors.
DISCUSSION: Erythromelalgia is a rare functional vascular disorder of the extremities characterized by
paroxysmal, bilateral, symmetric episodes of burning, erythema, pain, and occasional swelling, with a
local elevation in temperature that is exacerbated by dependency or heat and alleviated by elevation or
cool temperatures. The diagnosis is clinical and treatment with aspirin may result in improvement. As a
majority of cases are secondary, if erythromelalgia is suspected, patients should be evaluated for
underlying ailments, especially hematologic disorders.
338

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Sandeep M Patel, MD
A "Sluggish" Case of Renal Failure
Sandeep M. Patel, MD and Suzanne M. Norby MD
INTRODUCTION: Renal failure and hypothyroidism are common problems in hospitalized
patients. Usually presenting separately, the occurrence of one does not affect the other. However, the
potential relationship is underappreciated, requiring a high index of suspicion to diagnose this rare but
reversible cause of kidney disease.
CASE PRESENTATION: A 68-year-old male with a history of hypertension treated with lisinopril
presented with worsening fatigue, confusion, and gait imbalance. His wife noted that his voice had
become deeper and his speech much more slowed.
On physical exam, temperature was 36.1 C, blood pressure 144/88 mmHg, and pulse 52 beats per
minute. His mentation was sluggish; speech was slow, and voice was deep. Alopecia and periorbital
edema were present. Skin was, paper-thin, profoundly dry, and cracked as well as sallow and yellowish
in color. The thyroid was firm and nontender with mild symmetrical enlargement without
nodules. There was non-pitting edema of both lower extremities. The proximal musculature of all four
limbs was atrophic. Peripheral deep tendon reflexes were decreased. The remainder of the exam was
unremarkable.
Laboratory studies revealed hyponatremia (133 meq/L [135-145]), hypercalcemia (ionized level 6.21
mg/dL [4.8-5.7]), normocytic anemia (hemoglobin 10.4 g/dL) and serum creatinine level of 2.4 mg/dL
(0.8-1.3) [baseline 8 months ago 1.5 mg/dl ] with blood urea nitrogen level 33 mg/dL (8-23). Urinalysis
with microscopy was normal. Renal ultrasound with Doppler imaging revealed increased cortical
echogenicity bilaterally with patent renal arteries and veins. In lieu of the physical findings, the thyroid
gland was evaluated. Thyroid-stimulating hormone level was 94.1 mIU/L (0.3-5.0), and T3 and T4 levels
were undetectable. Thyroid peroxidase antibody level was > 950 IU/mL ( 500 IU/mL (

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Chaithra Prasad, MD
Forgotten Sequelae
Chaithra Prasad, MD, Bharath Palraj, MD
INTRODUCTION:Infliximab is a monoclonal anti-tumor necrosis factor alpha antibody used increasingly
frequently in the management of inflammatory bowel disease and rheumatoid arthritis. Infliximab
therapy has been associated with serious infections including disseminated tuberculosis (TB), invasive
fungal infections and bacterial infections like Listeria and Legionella. Active cases of TB can include
reactivation of latent TB and less frequently, primary TB. This case highlights the importance of (1)
screening for TB prior to initiation of infliximab and (2) considering TB in the differential diagnosis of
lung infiltrates in patients on infliximab.
CASE PRESENTATION: An 18-year-old female high school student from Iowa with a 3-year history of
ulcerative colitis on infliximab therapy initially presented to her primary care physician with severe
cough, dyspnea, fever, and worsening abdominal pain. Details of the outside physical examination
findings are unavailable but we know a CT-abdomen that captured the lung bases was performed,
revealing nodular bibasilar lung infiltrates and no intra-abdominal pathology. She was prescribed a 2week
course of ciprofloxacin, amoxicillin, clarithromycin, and prednisone. She improved to the point
that she could resume classes and her part-time job at a pizza joint. However, her symptoms recurred
within a week of having discontinued her antimicrobial regimen and she presented for reevaluation.
Physical examination revealed a febrile and tachypneic thin Caucasian female with diffusely
coarse breath sounds and notably bronchial breath sounds in the left upper lung field. WBC count was
3500/mL. CT-chest showed diffuse miliary nodular lung infiltrates with a focal area of consolidation in
the left upper lung extending to the hilum and bilateral hilar adenopathy. CT-abdomen showed ascites
with peritoneal and splenic nodules. Bronchoalveolar lavage smear was positive for acid-fast bacilli and
culture grew Mycobacterium TB sensitive to all 4 first-line drugs. She had traveled only within the
United States and had no history of incarceration or known TB exposure. She was unsure whether she
had received TB screening prior to infliximab initiation. After 9 months of the anti-TB regimen, the
patient’s cough, fever, dyspnea, and abdominal pain had resolved and repeat imaging showed complete
resolution of the pulmonary infiltrates, adenopathy, as well as the peritoneal and splenic nodules.
DISCUSSION: Internists are likely to see the forgotten sequelae of medications initiated by
subspecialists. Biologicals targeting different arms of the immune system are being widely used in
various inflammatory conditions. Either reactivation or primary TB can develop after the initiation of
infliximab and can result in disseminated military TB. This case highlights the importance of TB
screening before starting infliximab as well as the importance of considering TB in the differential
diagnosis of lung infiltrates in the infliximab-treated patient.
340

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE David Raslau, MD
Methotrexate Toxicity: When The Treatment Is Worse Than The Disease
David Raslau, MD
INTRODUCTION:Methotrexate is routinely used in the management of leukemias and lymphomas. It’s
wide spread use has revealed rare complications that were not previously known, specifically that some
patients can develop very high concentrations of methotrexate from either peripheral or intrathecal use
which can sometimes lead to encephalopathy. Most cases are benign and resolve on their own, but
there are reports of fatalities as well. This case highlights an episode of methotrexate-induced
encephalopathy that was prolonged and required further intervention.
CASE PRESENTATION: A 53 year old male who was recently diagnosed with large B cell lymphoma was
admitted to the hospital for high-dose methotrexate as part of cycle #1 of CODOX-M. He received his
medications per protocol and urine alkalinization and leucovorin rescue were started, again per
protocol. However, his 48-hour methotrexate level was extremely elevated at 118.75 mcmol/L. He also
started to develop signs of encephalopathy consisting of altered mental status with confusion,
disorientation, visual and auditory hallucinations, dysarthria, expressive aphasia, and pathological
reflexes which were suggestive of methotrexate-induced encephalopathy. A head CT was obtained
which was normal. He was transferred to an intensive care unit where he was started on continuous
renal replacement therapy until his methotrexate level was reduced to 1.44 mcmol/L.
Because of this episode he also developed acute renal failure with his creatinine increasing from a
baseline of 0.6 mg/dL to 2.8 mg/dL. His renal function stabilized but did not fully recover during the rest
of his hospitalization. On dismissal from the hospital, his creatinine remained elevated at 2.3 mg/dL.
He was transferred back to the floor where rescue measure with urine alkalinization and leucovorin
were continued. However, he was not making much progress. We decided to try treating with
dextromethorphan as there has been some discussion about its potential benefit in the situation and
even some literature regarding its use. He was started on dextromethorphan and within 24 hours his
encephalitis started to improve. By 72 hours, his symptoms had almost completely resolved. During this
time, his creatinine only mildly improved from a level of 2.8 to 2.5 mg/dL. His methotrexate level finally
returned < 0.1 mcmol/L and he was dismissed from the hospital. Over the next several weeks, his
mental status and renal function returned fully to baseline.
DISCUSSION: This highlights one of the rare but severe side effects of methotrexate. It also seems to
suggest that dextromethorphan can be used to aid in combating methotrexate-induced encephalopathy
as there were no other treatments giving during the time of his clinical improvement and his renal
function did not improve significantly. An argument can be made that he should have remained on
continuous renal replacement therapy until the methotrexate was fully cleared. This may have been
beneficial in this patient. Further studies will be needed to determine the pathogenesis of
methotrexate-induced encephalopathy as well as the role of continuous renal replacement therapy and
dextromethorphan in cases of methotrexate-induced encephalopathy.
341

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE John T Ratelle, MD
Shortness of Breath and Fatigue: Common Symptoms with an Uncommon Culprit
John T Ratelle, MD Additional authors: Mark Wieland, M.D. Andre C. Lapeyre, III, M.D.
INTRODUCTION: CASE PRESENTATION: A 57 year-old female presented to clinic with a two week
history of fatigue and shortness of breath. Review of systems was positive for orthopnea. She denied
chest pain, cough, edema, fevers, chills, or weight loss. Her past medical history was significant for
hemoglobinopathy E and Tak mutation manifesting as a stable, asymptomatic erythrocytosis, as well as
depression. Her only medication was paroxetine 10 mg daily. Vital signs were normal. Cardiac
auscultation revealed a 1/6 diastolic murmur. There was no jugular venous distension or peripheral
edema. Lungs were clear. The remainder of the physical examination was unremarkable. Laboratory
evaluation, including CBC, TSH, and electrolytes, were normal or unchanged. Chest x-ray was remarkable
for cardiomegaly with mild interstitial edema. Electrocardiogram showed evidence of left atrial
enlargement. Based on these findings and progressive symptoms, an echocardiogram was performed
which revealed a left atrial mass attached to the superior aspect of the interatrial septum measuring
5.82 x 3.46 cm with associated mitral obstruction during diastole. Her right ventricular systolic pressure
was elevated at 52 mmHg; left ventricular ejection fraction was normal. The patient was referred to
cardiology and cardiovascular surgery. She underwent subsequent excision of the left atrial tumor;
pathology revealed a myxoma. Her hospital course was uneventful and she was discharged on hospital
day #5. The patient’s symptoms resolved after surgery.
DISCUSSION: Myxomas are the most common primary cardiac neoplasm, but remain rare with an
incidence of 0.5 per million. Most myxomas (75%) occur in the left atria and physical examination may
reveal a mid diastolic murmur and a classic mid-diastolic “tumor plop"1-3. Cardiovascular symptoms
(cough, shortness of breath, syncope) are the most common on presentation, found in up to 70% of
patients. Constitutional symptoms may also be present in a third of patients that are thought to be
secondary to release of inflammatory cytokines from the tumor. Systemic embolization may be present
in one third of patients on presentation4. Once the diagnosis of myxoma has been made, treatment
consists of prompt surgical resection because of the risk for systemic embolization as well as sudden
death3,4. Surgical outcomes are generally good and most patients achieve resolution of her symptoms.
Myxomas may recur in 5-10% of cases1,4. In conclusion, myxomas are a rare entity that can present
with common office complaints including fatigue, shortness of breath and weight loss.
342

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Julio C Sartori-Valinotti,
MD
A case of fever of not-so-unknown origin
Julio C Sartori-Valinotti, MD Lia C. Kaufman, MD M. Rizwan Sohail, MD
INTRODUCTION: Deciphering the enigma of fever of unknown origin (FUO) can be rewarding if the
diagnosis can be made in a timely manner to allow appropriate treatment. Unfortunately, despite
important advances in diagnostic techniques, working up FUO remains a difficult task.
CASE PRESENTATION: A 49-year-old previously healthy man presented to his local hospital with a 3day
history of malaise and low-grade fevers. He was treated with azithromycin for presumed sinusitis
and dismissed. However, symptoms persisted, prompting a second visit where he was prescribed
doxycycline for suspected tick-borne illness. Unfortunately, his condition worsened, and so he sought
care at another institution, where he was found to be pancytopenic, instigating admission and empiric
broad spectrum anti-bacterial and antifungals therapy. An extensive work-up for infectious diseases was
initiated, including bacterial, fungal and mycobacterial blood cultures, viral and fungal serologies, and
CSF analyses that were all unremarkable. Labs were significant for an elevated ferritin at 3356 ug/L
(normal 11-307 ug/L), and liver transaminases that were 5 times the upper limits of normal. CT of the
abdomen revealed splenomegaly. Bone marrow biopsy (BMB) demonstrated features of myelodysplastic
syndrome and filamentous organisms. The diagnosis of hemophagocytic lymphohistiocytosis (HLH) was
made and patient was started on cyclosporine, methylprednisolone and rituximab. In spite of this, his
fevers persisted. The filamentous forms seen on the BMB were felt to be contaminants and antifungals
were discontinued. After 21 days of hospitalization without any clinical improvement, the patient was
transferred to our institution for further evaluation, where he was kept on vancomycin and imipenem.
Repeat BMB showed hypocellular marrow with necrosis and hemophagocytosis. GMS stain suggested
mycobacterial or Nocardia infection. Liver biopsy revealed occasional thin AFB within histiocytes. On
hospital day 5, outside blood cultures obtained prior to transfer grew AFB, which tested negative for
Mycobacterium avium complex. Antibiotics were switched to imipenem and azithromycin for atypical
mycobacterial coverage, and trimethoprim-sulfamethoxazole was subsequently added to cover
possibility of nocardia. On day 8, the patient became hemodynamically unstable and emergent
echocardiogram revealed a mobile thrombus in the right atrium. The patient died later that day. A few
hours later, blood cultures from outside hospital and our institution were reported to grow
Mycobacterium kansasii. Autopsy revealed systemic granulomatosis, involving spleen, brain,
thoracoabdominal lymph nodes, liver, bone marrow, and lungs positive for AFB.
DISCUSSION: HLH is a rare and often fatal condition characterized by immune dysregulation and nonspecific
activation of macrophages resulting in phagocytosis of erythrocytes, leukocytes, platelets and
their precursors. It can present as a primary process due to a genetic defect, or secondary to infections
(most commonly EBV), or autoimmune disorders. Mycobacteria-driven HLH is an unusual entity rarely
reported in the literature. However, it is an important diagnosis to consider when evaluating a case of
FUO.
343

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Julio C Sartori-Valinotti,
MD
A case of cryptogenic hemoptysis, deciphered.
Julio C Sartori-Valinotti, MD Charles F. Thomas, MD
INTRODUCTION: Reaching an ultimate diagnosis for intermittent hemoptysis can be both challenging
and frustrating. Indeed, in spite of extensive evaluation including repeated use of bronchoscopy, the
precise etiology remains unclear in 25 to 30% of patients.
CASE PRESENTATION: A 75-year-old man presented to the pulmonary clinic for a second opinion
regarding one-year history of intermittent hemoptysis, cough and unintentional weight loss. His past
medical history was significant for squamous cell lung carcinoma s/p left pneumonectomy and
chemotherapy five years prior. He had undergone extensive evaluation at an outside facility. CT of
chest/abdomen/pelvis showed changes consistent with left-sided pneumonectomy but no mediastinal,
hilar or axillary lymphadenopathy or pleural pathology. Outside bronchoscopy indicated small amount of
blood coming from the left endobronchial stump but no evidence of tumor hence no biopsies were
obtained and no interventions were undertaken. Repeat CT five months later demonstrated interval
development of mediastinal lymphadenopathy, areas of attenuation within the liver and spleen, and
small amount of fluid or soft tissue with displacement of the mediastinum to the left. These findings
prompted biopsy of the lung, lymph nodes, stomach, liver and spleen. The latter was complicated with
chest wall MRSA abscess which was drained and treated with antibiotics. All biopsies were negative for
malignancy. At our institution we proceeded with PET scan that demonstrated hypermetabolic masses
along the left pleural surface with an SUV max of 9.5 (Figure 1), hypermetabolic soft tissue mass in the
left chest wall corresponding to prior abscess and diffuse bone marrow hypermetabolism possibly
induced by severe infection. MRI of the brain did not suggest brain metastasis. Bronchoscopy revealed a
diffuse mucosal lesion in the distal trachea and left pneumonectomy stump (Figure 2) along with a
defect in the left pneumonectomy stump compatible with bronchopleural fistula (BPF). Multiple biopsies
of the diffuse mucosal lesion revealed squamous metaplasia and inflammation without evidence of
tumor. Similarly, the BAL cytology was negative for malignancy. The patient underwent thoracotomy for
empyema debridement, muscle flap closure of the BPF, and Clagget procedure.
DISCUSSION: Although pneumonectomy remains the most common cause of BPF, the diagnosis can be
easily missed, particularly in the setting of misleading symptoms or imaging findings. Bronchoscopic
saline instillation against the stump is a simple method to test the stump integrity. A high level of
suspicion is needed to avoid delay treatment and complications.
344

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Joseph H Skalski, MD
Erdheim-Chester Disease with Right Atrial Pseudotumor and Temporal Arteritis
Joseph H Skalski, MD William D. Edwards, M.D. Eric L. Matteson, MD, MPH
INTRODUCTION:A 71 year-old man presented with three months of severe headache, dyspnea on
exertion, fever, and unintentional weight loss of approximately 30kg. His past medical history included
well-controlled diabetes mellitus type 2, hypertension, hyperlipidemia, and end stage renal disease on
hemodialysis. His end stage renal disease had developed over the previous year and had been attributed
to diabetes without confirmation by renal biopsy.
CASE PRESENTATION: A 71 year-old man presented with three months of severe headache, dyspnea
on exertion, fever, and unintentional weight loss of approximately 30kg. His past medical history
included well-controlled diabetes mellitus type 2, hypertension, hyperlipidemia, and end stage renal
disease on hemodialysis. His end stage renal disease had developed over the previous year and had
been attributed to diabetes without confirmation by renal biopsy. He otherwise had minimal medical
history and prior to this illness was active, vigorous, and independent.
The patient was initially hospitalized for four weeks at another institution where the dyspnea was found
to be due to bilateral pleural effusions. Analysis of pleural fluid was nondiagnostic. Head magnetic
resonance imaging (MRI) and cerebral spinal fluid analysis were unrevealing. Temporal artery biopsy
was performed to further evaluate the headache demonstrating an inflammatory arteritis. He later
developed tachy- and brady- arrhythmias and sustained an asystolic cardiac arrest. He was successfully
resuscitated and transferred to our institution. Upon arrival, his primary symptom was a severe
headache. Physical examination was unremarkable. Laboratory testing demonstrated markedly
elevated C-reactive protein at 192.7 mg/L. The remainder of the laboratory testing was unrevealing
including negative vasculitis and auto-antibody screening. Cardiac MRI demonstrated an infiltrating
right atrial mass as the probable cause of his arrhythmia. Percutaneous biopsy of the right atrial mass
demonstrated a foamy histiocytic infiltrate that stained positive for CD68 and negative for S100. A
diagnosis of Erdheim-Chester disease was made. The temporal artery biopsy slides were re-reviewed in
light of this diagnosis, and the arterial infiltrate was observed to be a CD68+ histocytic infiltrate
consistent with Erdheim-Chester disease. There is no standardized treatment for Erdheim-Chester
disease. In consultation with hematology, treatment was initiated with anakinra, an IL-1
antagonist. With treatment, our patient experienced significant improvement, including resolution of
headache. C-reactive protein was undetectable at

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Eoin R Storan, MBChB
An unusual presentation of Henoch Schönlein Purpura in an elderly female
Eoin R Storan, MBChB Co-Authors: Miguel Lalama MD Nandakumar Srinivasan MD Robert Kraichely MD
INTRODUCTION: Henoch Schönlein Purpura (HSP) is a form of systemic vasculitis which is most
commonly seen in children. It most frequently presents with the classical tetrad of a palpable purpuric
rash, arthralgia or arthritis, abdominal pain and renal disease. Adult patients with HSP present in a
similar fashion to children, and renal disease is particularly common in affected adult patients.
CASE PRESENTATION: A 71-year-old woman was admitted to hospital for evaluation of a one-month
history of nausea, anorexia, abdominal pain and increasing abdominal distention. Her physical
examination revealed a distended abdomen with tenderness in the epigastrium and the left lower
quadrant. There was dullness to percussion at the flanks consistent with ascites. The remainder of her
physical examination was within normal limits. Laboratory studies of note included a mild normocytic
anemia. Serum creatinine was within normal range and urinalysis was bland. The remainders of her
laboratory studies were within normal ranges. Autoimmune serological testing and celiac panel were
negative. Infectious work-up including stool studies with culture and Clostridium difficile toxin; blood
and urine cultures were negative.
CT of abdomen and pelvis showed free intraperitoneal fluid, thickening of the prepyloric region of the
stomach, the entire duodenum and proximal jejunum through to the ascending colon. CT angiography of
the abdominal vessels was normal. She underwent an ultrasound-guided large-volume paracentesis and
fluid analysis was negative for infection and malignancy. Esophagogastroduodenoscopy (EGD) showed
multiple esophageal and duodenal ulcerations. Biopsies were taken and showed non-specific
inflammation with negative cytomegalovirus (CMV) and Helicobacter pylori staining. She proceeded to
colonoscopy that revealed acute proctosigmoiditis. Colonic biopsies were taken and revealed mild active
colitis without specific features, with negative staining for CMV. One week after hospitalization she
developed a palpable purpuric rash on her upper and lower extremities, abdomen and trunk. A skin
biopsy was taken of her rash. This revealed superficial blood vessels, which stained positive for IgA
under direct immunofluorescence consistent with IgA-mediated vasculitis. She was diagnosed with Adult
HSP.
She received 3 days of parenteral methylprednisolone pulse therapy and her rash and abdominal pain
markedly improved. She was transitioned to high dose oral prednisone daily and she continued to
improve with resolution of her rash after 7 days. She was maintained on a slow tapering dose of oral
prednisone therapy.
DISCUSSION: This case posed a diagnostic challenge due to the initial absence of the characteristic
rash, the presence of ascites and the lack of renal involvement. Together with this patient’s advanced
aged, this heralded a low level of suspicion for an IgA-mediated vasculitis. This case highlights that HSP
can occur in the elderly population and may present in an atypical fashion.
346

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Karna K Sundsted, MD
Perilous Purpura: An Unusual Presentation of Renal Cell Carcinoma
Karna K Sundsted, MD, Jason Szostek, M.D.
INTRODUCTION: Henoch-Schönlein purpura (HSP) is a small vessel vasculitis that is characterized by
arthralgias, palpable purpura, abdominal pain and glomerulonephritis. It rarely occurs in adults. In
approximately 60% of adult cases, it is a manifestation of a solid tumor malignancy, suggesting clinicians
should consider occult neoplasm in adults who present with HSP.
CASE PRESENTATION: A 47-year-old man with a history of infectious eczematoid dermatitis was
admitted to the inpatient medicine service with a painful, progressive rash and disabling
polyarthritis. Since the onset of the rash two weeks prior, the patient was evaluated twice by
dermatology who ultimately diagnosed him with HSP based on clinical exam, otherwise normal
laboratory testing and punch biopsies showing leukocytoclastic vasculitis with weakly positive IgA. As an
outpatient, he was started on dapsone and topical treatments. At the time of hospitalization, the
patient reported progression of his rash and polyarthritis along with two recent episodes of severe
abdominal pain. He denied other symptoms or recent medication changes. On exam, the patient had
diffuse palpable purpura with ulcerations. Within 24 hours of hospitalization, the patient developed a
markedly edematous uvula manifesting as cough and sore throat. Oral prednisone 60 milligrams daily
was initiated along with ongoing use of wet dressings, topical steroids and dapsone. A chest radiograph
was negative, but computed topography of his abdomen showed a 1.6 centimeter solid right kidney
mass. He underwent a right partial curative nephrectomy with pathology revealing clear cell renal
carcinoma (RCC) and IgA nephropathy, in the setting of a normal creatinine and urinalysis. At the time
of three month follow-up, the patient’s rash and arthralgias had resolved without ongoing treatment,
and he has had no subsequent recurrence.
DISCUSSION: We report the case of an adult who was diagnosed with RCC in association with HSP. HSP
is a systemic vasculitis, resulting in the tissue deposition of IgA-containing immune
complexes. According to the American College of Rheumatology, the diagnosis of HSP requires at least
two of four criteria including palpable purpura, age less than 20, bowel angina and wall granulocytes on
biopsy. Although considered mainly a disease of children, it can rarely occur in adults. As of 2006, 31
cases of adult malignancy-associated HSP have been reported, predominantly solid tumors, with nonsmall
cell lung cancer most common. Of adult cases of HSP-associated solid tumor malignancy, RCC is
rare. Most frequently, HSP occurs within one month of the cancer diagnosis. The pathophysiology of
HSP in association with malignancy is not well understood, but it has been hypothesized that tumor
neoantigens may play a role. In most cases, HSP resolves after successful treatment of the associated
malignancy, as was the case in our patient.
347

MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Hemang Yadav, MBBS
Superwarfarin poisoning: a challenging coagulopathy
Hemang Yadav, MBBS Second Author: Dr C Christopher Hook, MD
INTRODUCTION: Superwarfarins are warfarin-like compounds that are markedly more potent and
lipophilic than warfarin itself. Superwarfarins are widely used as rodenticide. Poisoning, resulting in a
hemorrhagic coagulopathy, is increasingly seen. Not recognized unless clinical suspicion is high,
superwarfarin poisioning can be potentially devastating. We describe a case of accidental superwarfarin
ingestion and its challenging management.
CASE PRESENTATION: A previously healthy 40-year-old female presented to an emergency
department with bilateral flank pain, hematuria, frank hematemesis, hemoptysis, epistaxis and gingival
bleeding. Coagulation studies were significant for a prothrombin time (PT) over 130 seconds, INR of over
10 and partial thromboplastin time (PTT) of 105 seconds. She was anemic, with a hemoglobin of 10.7. CT
Abdomen/Pelvis was negative for retroperitoneal bleed. She was given 4 units fresh frozen plasma (FFP),
5 mg vitamin K and transferred to the Mayo Clinic for further evaluation.
Further history was obtained on arrival. She had no history of coagulopathy and had prior surgeries
without bleeding complications. She denied significant family history, travel or exposures. Further
testing was performed (Table 1). Platelets, fibrinogen and peripheral smear were normal. Inflammatory
markers were not elevated. Liver function tests, including albumin, were also normal. After initially
improving to 4.1 with FFP, INR rebounded to 7.2. She continued to require daily FFP and vitamin K for
correction. Hematology was consulted.
She had special coagulation testing performed, with PT and aPTT showing significant prolongation,
largely corrected on the mixing studies. Factor studies showed deficiency of vitamin K-dependent
factors, including factors II, VII, IX, X. Warfarin level was undetectable. Superwarfarin testing by high
performance liquid chromatography (HPLC) was positive for Brodifacoum. The source of the ingestion
remains unclear. Attempted poisoning by ex-boyfriend's ex-girlfriend was suggested but never proven.
She was discharged on oral vitamin K, initially 20 mg every 4 hours but developed nausea and vomiting
with this. With vomiting episodes, her INR would increase, requiring FFP support. She transitioned to
subcutaneous vitamin K injections, 10 mg four times daily. She continues on 3-times weekly lab draws
(Figure 1), with FFP support for markedly elevated INRs. 10 months after diagnosis, her Brodifacoum
levels remain detectable. She has received over 50 units of FFP and around 20 g of vitamin K over this
time period. She has not had further bleeding episodes.
DISCUSSION: The "superwarfarins" (brodifacoum, coumafuryl, difenacoum, bromadiolone) are
lipophilic, long-acting rodenticides. Potency is approximately 100 times greater than warfarin. Half lives
are between 10 and 69 days, as opposed to 40 hours for Warfarin. Patients present with prolonged
PT/PTT that corrects with mixing studies, and selective deficiency of vitamin-K-related factors.
Superwarfarins are widely used as rodenticides throughout the United States and consequently toxicity
may present to the internist through accidental ingestion, particularly in rural areas, intentional
poisoning or intentional self-ingestion. Management is challenging due to the prolonged monitoring and
massive doses of vitamin K needed. The clinician needs to include superwarfarin ingestion in the
differential for patients presenting with unexplained coagulopathy (see algorithm, Figure 2). Diagnostic
testing through HPLC or mass spectrometry is available in regional centers.
348

MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Cory B Carter, MD
Chapter Winning Abstract - Double Trouble: Paraneoplastic Hypercalcemia-Hyperleukocytosis Syndrome
In Cutaneous Squamous Cell Carcinoma
INTRODUCTION: Less than thirty cases of humoral hypercalcemia of malignancy (HHM) secondary to
primary cutaneous squamous cell carcinoma (SCC) have been documented. In only a few of these cases
is the hypercalcemia concomitant with hyperleukocytosis, a finding known as hypercalcemiahyperleukocytosis
syndrome. In comparing these instances with those of hypercalcemia alone, survival
of patients with hypercalcemia-hyperleukocytosis syndrome appears to be shorter.
CASE PRESENTATION: A 54 year-old African-American male with recurrent cutaneous abscess
formation at the site of a proximal right thigh mass presented with three days of altered mental status.
A previous biopsy of the mass demonstrated moderately to well-differentiated SCC. On initial
presentation to our hospital he had a serum calcium of 15.9 mg/dl and a WBC count of 15,800. A CT of
the head showed multiple low-density lesions suspicious for metastatic disease, and a CT of the
abdomen and pelvis revealed a large loculated mass in the medial right thigh with local invasion. A PET
scan did not show any areas of hypermetabolic activity of the lung. The patient was given aggressive IV
hydration, as well as bisphosphonate and calcitonin therapy. 25-hydroxy vitamin D as well as PTH levels
were both below normal range, and a parathyroid hormone-related protein (PTHrP) level was elevated.
These findings best represented paraneoplastic production of PTHrP from a primary cutaneous SCC. The
patient experienced only mild improvement of his mental acuity and hypercalcemia. He declined
palliative chemotherapy and radiation therapy, and he was discharged to a hospice and died several
days later.
DISCUSSION: Although HHM has been identified in a significant number of primary SCC of the lung, it
has only rarely been reported with cutaneous SCC. Even more exceptional is the presence of
concomitant hyperleukocytosis syndrome. We present a case of hypercalcemia-hyperleukocytosis
syndrome in relationship to cutaneous SCC, of which only a small number of cases have been reported.
This case supports the finding that the presence of this paraneoplastic combined process is a poor
prognostic indicator. Future studies may indicate that the presence of hypercalcemia-hyperleukocytosis
syndrome may independently predict survivability when compared to the use of standard TNM staging.
349

MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Daniel Robert Hatcher,
DO
Chapter Winning Abstract Rickettsia Parkeri, An Emerging Spotted Fever Group Rickettsiosis
Daniel Robert Hatcher, DO (Associate) Peter Blatz, MD (Member) Erin Weeden, MD Nicholas G. Conger,
MD (Member)
INTRODUCTION: The most common cause of spotted fever in the United States is Rocky Mountain
Spotted Fever (RMSF) caused by Rickettsia rickettsii. However, multiple regionally associated and
vector specific reckettsiae species have been identified. Recently, Rickettsia parkeri has been described
as an emerging pathogen, causing an eschar-associated Spotted Fever Group Rickettsiosis (SFGR) in the
SE US region, including the Gulf Coast.
CASE PRESENTATION: #1 A 57-year-old male, who lives and works in a wooded area adjacent to a
swamp in Louisiana, presented with a painful pustule on his right shin following a stinging bite to that
area. He was given cephalexin 500mg QID empirically without improvement. Over the next 5 days, the
wound progressed to a 1.5 cm black eschar with surrounding erythema. The patient subsequently
developed chills, fever to 102.6F, headache, night sweats, and a spotted maulopapular red rash over this
torso and extremities. He had painful red nodules on his hands and fingers. ESR was 59. He was
treated with doxycycline with dramatic resolution of symptoms. Serology for SFGR AB IgG was positive
at 1:1024 and R. parkeri IgG was >1:512. Lesion biopsies revealed perivascular inflammatory cell
infiltrates involving the full thickness of the dermis, with focal vasculitis and panniculitis. Pathology
specimens sent to the CDC stained positive for SFGR organisms within the tissue. Given the
geographical area and clinical presentation, this is diagnostic for R. parkeri.
#2 A 48-Year-Old man was sent for consultation for suspected Lyme disease following a tick bite. This
patient had fever, chills, diffuse myalgias, arthralgias, and developed a spotted rash. All symptoms
dramatically improved with doxycycline. Lyme Ab was repeatedly negative, but SFGR AB IgG was
positive at 1:256 four weeks after presentation and R. parkeri IgG was 1:512. The constellation of
symptoms, positive AB, and geographic location where the bite was sustained is highly suggestive of R.
parkeri rickettsiosis.
DISCUSSION: Close attention needs to be paid in a suspected SFGR to its distinguishing characteristics
for an accurate diagnosis and prognosis. These cases illustrate classic presentations for Rickettsia pareri,
an emerging infectious disease that is very similar to, thought less sever than Rocky Mountain Spotted
Fever. Case reports are few, and cases occur from the east coast of Texas to Florida, clustering around
the South-East US coastal areas. Cases are likely either missed, or mistaken for RMSF or Lyme disease,
neither of which are reported to occur in these areas. It is important for health care providers in the
coastal regions inhabited by Amblyomma maculatum to be aware of this infection, and to treat
appropriately with doxycycline.
350

MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Dane Ballard
Brainstorm: A Case Report Of N-methyl-d-aspartate Receptor Antibody Encephalitis
; Dane Ballard MD, George Abraham MD
INTRODUCTION:Anti-N-Methyl-D-Aspartate receptor (NMDAR) antibody encephalitis is a newly
recognized syndrome that causes severe psychotic and neurologic symptoms, which rapidly prove fatal
if not recognized and treated early. A single institution has reported over 400 cases in just over 3
years[1] suggesting that it may be the most common antibody associated with encephalitis. Here we
present a case of NMDAR encephalitis that occurred as a paraneoplastic manifestation of bilateral
ovarian teratomas
CASE PRESENTATION: A 16-year old woman presented to the Emergency Room after an altercation
with her father. Her mother reported a one week history of psychotic symptoms including: insomnia,
severe agitation, combativeness, and auditory hallucinations. The patient was confused, lacked insight,
and exhibited a tangential thought process. She was discharged from the Emergency Room to a
pediatric mental health facility where she was started on haloperidol, olanzapine, and depakote. Five
days after admission she developed a fever of 105 degrees Fahrenheit, exhibited diffuse muscular
rigidity, and became unresponsive. She was admitted to the medical ICU, intubated, and treated with
dantrolene for presumed neuroleptic malignant syndrome. After 4 days of supportive care and failure to
improve on dantrolene, a CT abdomen was performed and revealed bilateral ovarian masses consistent
with ovarian teratomas. A lumbar puncture was performed and sent to the Mayo Clinic for work-up of a
suspected paraneoplastic syndrome. On day twelve of her hospital course the tumors were resected;
pathology later confirmed the masses to be poorly differentiated teratomas. The patient was treated
empirically for NMDAR encephalitis with intravenous immunoglobulin and plasma exchange, however,
she did not improve with therapy. She remained unresponsive and exhibited choreiform movement,
which was unsuccessfully treated with haloperidol, phenobarbital, and ziprasidone. Thirty-five days
after admission she was weaned from the ventilator, and one week later the NMDAR antibody returned
positive. Several days later she was discharged from the ICU, to the general ward. She remains
unresponsive and does not follow commands.
DISCUSSION: This case was diagnostically and therapeutically challenging, and highlights the
masquerading nature of this disease. We emphasize the importance of ruling out organic causes of
psychosis, especially in young adults and children. We also stress the need to develop more rapid
diagnostic tests for serum and cerebrospinal fluid.
[1] Josep Dalmau, MD, Eric Lancaster, MD, Eugenia Martinez-Hernandez, MD, Prof Myrna R Rosenfeld,
MD, and Prof Rita Balice-Gordon, PhD, Clinical experience and laboratory investigations in patients with
anti-NMDAR encephalitis, Lancet Neurology, Volume 10, issue 1, January 2011, pages 63-74
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3158385/?tool=pubmed)
351

MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Alycia Cleinman, MD
The Case of the mysterious fever and rash: DRESS Syndrome caused by Goserelin
Alycia Cleinman, MD Justin Qualls, MD Andree Burnett, MD
INTRODUCTION: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is defined
by the presence of a rash with three additional criteria of: fever, hematologic abnormalities,
lymphadenopathy, or organ involvement. DRESS syndrome is typically of delayed onset, occurring 2 to 6
weeks after initiation of the offending drug. Goserelin has been previously associated with local skin
reactions, but not DRESS syndrome. Here, we present the first reported case of DRESS syndrome
associated with goserelin.
CASE PRESENTATION: A 65-year-old white man with known prostate cancer presented to an
emergency department with fever and diffuse rash. Two weeks prior to presentation, the patient
received a depot injection of goserelin. He subsequently developed a local pruritic rash on his chest that
later progressed to his arms, legs, palms, groin, and buttocks; two days prior to presentation he
developed a high-grade fever.
Initial examination revealed hepatosplenomegaly. In addition, an erythematous maculo-papular rash,
was present on his abdomen, buttocks, back, and palms, as well as on all extremities, but spared his
mucosa. During his hospitalization, the rash developed a targetoid appearance. Admission labs revealed
bandemia without eosinophilia and a mild AST elevation. Within a few days, eosinophilia developed with
resolution of the AST elevation. Additional investigations failed to identify an auto-immune, viral, or
bacterial etiology. History revealed no possible exposures other than goserelin, to account for the
presenting symptoms.
The patient was empirically initiated on systemic and topical corticosteroids for a suspected adverse
reaction to goserelin. A skin biopsy of the left gluteal region was performed and pathology reported
“superficial perivascular lymphohistiocytic dermatitis with eosinophils and neutrophils”. Dermatology
was consulted and confirmed the clinical presentation was consistent with DRESS syndrome, likely due
to goserelin. Upon discussion with Urology, it was revealed that the injection would last for three
months with no possible intervention for its discontinuation.
DISCUSSION: We present here a unique case of DRESS syndrome, likely caused by goserelin. Our case
highlights the importance of considering depot goserelin injections as a cause of DRESS syndrome. While
we were unable to withdraw the offending drug, our patient’s outcome was still favorable. We attribute
this to his completion of a course of corticosteroids and our careful observation of the patient’s
subsequent clinical course.
352

MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Sushant Khaire, MBBS
Electrocardiographic Brugada Pattern Induced By Quetiapine Overdose
Sushant Khaire, MD Other Authors: Harsha Nagarajarao, MD; Santo Marcus Borganelli, MD; Robert
Marshall, MD; Senior Author: Ernest Matthew Quin, MD.
INTRODUCTION: Brugada syndrome is a genetic disorder characterized by a mutation in the sodium
channel SCN5A gene; affected individuals have an abnormal electrocardiogram (ECG) pattern, and
sudden cardiac death can occur due to cardiac arrhythmias. ECG patterns similar to Brugada syndrome
have been observed with the use of certain drugs, including sodium channel blocking Class I
antiarrhythmic drugs, selective serotonin reuptake inhibitors (SSRI), tricyclic antidepressants (TCA), and
other antidepressants. In some patients this is thought to be related to an inducible Brugada pattern,
which may also be associated with cardiac arrhythmias. Here we present a case of induced Brugada
pattern due to quetiapine overdose.
CASE PRESENTATION: A sixty-one year old male was brought to the emergency department following
a suicide attempt by overdose of quetiapine and zolpidem. He had recently started quetiapine after
stopping citalopram. On presentation he was awake, but confused and agitated. He was
hemodynamically stable, diaphoretic, had pinpoint pupils, and a flushed appearance. He had tremors in
all four extremities. ECG on presentation showed ST-segment elevation in V1, V2 and V3 consistent with
Brugada pattern. Troponin and electrolytes were within normal ranges. He was admitted to the
intensive care unit and quetiapine and zolpidem were held. Serial ECGs demonstrated eventual
normalization of ST segments QT interval. Mental health was consulted and he was eventually
transferred for medication adjustments, but had no arrhythmias during the hospitalization.
DISCUSSION: Brugada pattern on ECG can be induced by several factors including medications
mentioned above as well as lithium, cocaine, bupivacaine, propofol, verapramil, beta blockers, and
nitrates. Here we present the first reported case, to our knowledge, of Brugada pattern induced by
quetiapine. Optimal management for patients who have transient Brugada pattern induced by
medications is not clear, although most seem to have a good prognosis. While genetic defects such as
those associated with the SCN5A gene can be unmasked by certain agents, the arrhythmic risk
associated with mutations having low penetrance is not currently known. In selected cases with
syncope or palpitations consistent with a cardiac arrhythmia, further electrophysiologic evaluation may
be beneficial. Based on the occurrence of Brugada pattern with quetiapine and other antidepressant
medications, however, screening with baseline and periodic ECGs is warranted.
353

MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Sanjay H Maniar, MD
The Myocardial Bandit: A Case Of Left Internal Mammary Artery Steal Phenomenon
; Sanjay Maniar, MD, Elisa Bradley, MD and Edward Geltman, MD
INTRODUCTION:
Coronary artery bypass graft (CABG) has remained the long-standing definitive therapy for multi-vessel
coronary artery disease (CAD). The left internal mammary artery (LIMA) is generally considered the
vessel of choice for revascularization of the left anterior descending artery (LAD). The mammary steal
phenomenon has been described as the interval development of angina due to the reversal of blood
flow within a previously constructed internal mammary artery coronary conduit. We present a unique
case of the steal phenomenon due to a fistulous connection between the proximal LIMA with the left
pulmonary veins.
CASE PRESENTATION: A 78-year-old white gentleman with history of coronary artery disease, threevessel
coronary artery bypass graft (CABG) (LIMA to left anterior descending artery (LAD), saphenous
venous graft (SVG) to a diagonal artery, and SVG to posterior descending artery), congestive heart
failure and dual-chamber pacemaker placement who presented with recurrent chest pain and dyspnea
on exertion. His chest pain began in his distal left arm and progressed proximally at rest, worsened with
exercise and resolved following the administration of nitroglycerin. All labs, including troponin-I and
creatinine kinase MB fraction (CK-MB) were within normal limits. Electrocardiogram demonstrated no
changes. Regadenoson nuclear stress test was unchanged from previous, showing a moderate-sized
anteroapical infarct and large infero- and inferolateral infarct. Cardiac catheterization demonstrated a
fistulous connection between the LIMA graft and an intercostal artery side branch emptying to the left
atrium via the pulmonary veins. Follow-up exercise treadmill nuclear stress test was suboptimal to
evaluate for ischemia in the territory of the LIMA graft due to attenuated heart rate response. The
patient ultimately underwent coil embolization of the fistulous connection, which resulted in improved
blood flow to his LAD. Following the procedures, he had symptomatic improvement and increased
exercise tolerance.
DISCUSSION: Mammary steal phenomenon has been variably documented and is a rare cause of
recurrent angina in patients who have previously undergone CABG surgery, specifically when LIMA side
branches have not been ligated. Current theories regarding the etiology of preferential flow is the
presence of lower peripheral resistance in the pulmonary vascular bed, compared to higher coronary
resistance. The patient underwent successful coil embolization with immediate symptomatic
improvement. This case highlights the potential for symptomatically significant blood flow steal from
unligated LIMA side branches, which can compromise flow to the coronary vascular bed, and the novel
advances in therapy available in the current era of medicine.
354

MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Sina Jasim, MD
Foot Drop and Urinary Retention Following Disseminated Varicella Zoster Infection
Sina Jasim, MD Co- authors: Srikanth Damodaram,MD, Stanley Iyadurai,MD, Ganesh Kudva, MD
INTRODUCTION: Herpes Zoster virus infection is usually associated with sensory nerve damage. Motor
neuropathy secondary to Zoster infection has been rarely reported and mostly affects the facial nerve.
Nerves of the lower limbs and the sacral spinal cord are usually spared. Here, we report a rare
presentation with foot drop and bladder dysfunction associated with varicella zoster virus (VZV)
infection, indicating discrete involvement of central and peripheral nervous systems.
CASE PRESENTATION: A 73-year old woman with chronic lymphocytic leukemia, presented with a 2week
history of walking difficulty. The patient was initially evaluated for back pain one month prior and
had received a local steroid injection with no improvement. Approximately a week after the steroid
injection, she noticed that the pain involved the right leg, and that she had difficulty walking. The
patient also reported difficulty voiding during the same period of time. Notably, she had also
complained of a “rash” on the right forehead prior to the steroid injection, which became worse to
involve the arms, trunk and legs.
Examination revealed multiple healing erythematous, crusting skin lesions on the face and right
forehead, as well as scattered lesions on the trunk and the arms. Confluent erythematous crusting
lesions were noted on the antero-lateral aspects of the right leg. Significant weakness of the right
peroneal-innervated muscles was noted. The right ankle reflex was absent. Abdominal examination
revealed suprapubic fullness and urinary retention was confirmed by measurement of post-void residual
volumes.
Basic laboratory evaluation revealed an increased white blood cell count consistent with chronic
lymphocytic leukemia. Lumbar puncture revealed a nucleated cell count of 245 (91% lymphocytes),
normal protein and glucose, and elevated VZV immunoglobulin titer. Serological evaluation revealed
elevated Varicella Zoster antibody titer. Biopsy of the skin lesion revealed the presence of VZV DNA, as
demonstrated by positive polymerase chain reaction. MRI of the thoracic and lumbar spine did not
reveal spinal cord compression or involvement. Nerve conduction study showed evidence of right sciatic
neuropathy with complete involvement of the right peroneal nerve and partial involvement of the tibial
nerve. The patient was treated with acyclovir and gabapentin. The urinary retention was treated with
intermittent catheterization and bladder training, and the foot drop with assistive devices.
DISCUSSION: VZV usually affects the dorsal root ganglion and corresponding dermatomes.To our
knowledge, this is the first case to document a discrete involvement of central and peripheral nervous
systems secondary to infection with VZV, suggesting multifocal vasculitis/vasculopathy as an etiology.
This observation adds to the spectrum of neurological complications of VZV in immune-compromised
host. From a clinical standpoint, the use of steroids in the context of VZV infection should be rigorously
examined.
355

MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Anilkumar Katta, MD
Common Variable Immunodeficiency (CVID): Gotta Know The Common Stuff!!!
Anilkumar Katta MD,Walter Gribben MD,James Temprano MD. Department of Internal Medicine,
Division of Immunobiology, Allergy and Clinical Immunology section, Saint Louis University, St. Louis MO.
INTRODUCTION: Common variable Immunodeficiency (CVID) is the commonest symptomatic primary
immunodeficiency characterized by impaired B-cell differentiation with defective immunoglobulin
production. CVID poses challenges to the internist because of its heterogeneity in presentation, delay in
diagnosis, recurrent infections and common misconception of being “a rare disease”.
CASE PRESENTATION: A 19-year-old active duty marine with history of chronic sinusitis s/p sinus
surgery and recurrent pneumonias presented to outpatient clinic with back pain, he was treated with
Vicodin and Flexril. Over the course of 5 days he developed dizziness, worsening of back pain, nausea
and vomiting. In this visit he was prescribed physical therapy. After this visit patient fell downstairs and
became unresponsive. In ED physical exam was significant for dilated and fixed right pupil. Head CT
revealed dilated ventricles and left thalamic infarct, emergent vetriculostomy was performed. Patient
was intubated and transferred to ICU. CSF culture and blood cultures grew Streptococcus Pneumoniae.
Patient continued to have high fever and high WBC count even with broad-spectrum antibiotic
coverage; CT scan of chest, abdomen and pelvis were performed which revealed pyomyositis with six
different abscesses all over the body. Immunodeficiency was suspected, further work up revealed that
patient is HIV non-reactive and has very low levels of IgG, IgM and IgA. Peripheral blood flow cytometry
showed decreased B-lymphocytes and absent switched memory B-lymphocytes confirming the diagnosis
of CVID. Patient was treated with IVIG, aggressive debridement and prolonged course of antibiotics.
After 3 months of hospital stay patient was discharged to rehabilitation.
DISCUSSION: High index of suspicion is needed for the diagnosis of CVID as patients most often present
with recurrent sinopulmonary infections and early diagnosis improves the mortality. Most often
patients are diagnosed form 5-10 yrs after the onset of CVID. Jeffrey Modell foundation's "10 warning
signs of primary Immunodeficiency for adults" is a good screening tool for primary care providers for
identifying primary immunodeficiencies. CVID patients have poor response to vaccines and all live
vaccines are contraindicated.
356

NEVADA POSTER FINALIST - CLINICAL VIGNETTE Dinadelle B Viola, MD
AIDS Patient with Secondary Syphilis Presenting with Nonreactive FTA-AB: A Case Study
Dinadelle B. Viola, MD (Associate), Charles Krasner, MD (Member), University of Nevada School of
Medicine
INTRODUCTION: Syphilis is a sexually transmitted disease caused by the spirochete Treponema
pallidum. Syphilis infection can present and mimic wide varieties of clinical disease processes as well as
affect multiple organs in the body. This case describes an AIDS patient’s unusual presentation with
ocular syphilis and the difficulty of diagnosing the infection.
CASE PRESENTATION: The patient is a 42-year-old male with AIDS and chronic candida infections. His
CD4 count was 171 cells/ml and his viral load was 7000 copies/ml.
In May 2010, the patient was referred to an ophthalmologist after a three-month period of bilateral
visual flashes, floaters and decreased vision. He was diagnosed with diffuse chronic vitritis with
secondary optic neuritis from candida infections, and was treated with oral fluconazole. But after two
weeks of post-treatment follow-ups, he was found to have worsening retinitis and uveitis. Therefore, he
was admitted for empiric therapy with IV fluconazole. The treatment resulted in the reduction in the
amount of detritus in his eyes and improvement of the retinal lesions. The patient also reported some
improvement of his vision.
In June 2010, the patient’s blood tests showed a CD4 count of 238 and positive serology tests for HSV1
and HSV2. Tests for toxoplasma, lyme, nontreponemal and treponemal were negative. However, soon
after the test, his visual complaints recurred on each eye, two weeks apart. He was then treated for
herpetic endophthalmitis with IV acyclovir and underwent pars plana vitrectomy with intravitreal
antibacterial and antiviral injections. After that, he reported some vision improvement.
Repeat serological tests were done due to his recurrent visual complaints. Pertinent findings revealed
positive HSV1 and HSV2, reactive RPR, VDRL, and FTA-Ab with RPR titer of 1:1024. At that point, he was
treated with IV penicillin that resulted in complete resolution of his visual symptoms and his RPR titer
had decreased to 1:4.
DISCUSSION: This case illustrates two points: (1) the complexity of diagnosis in the immunecompromised
and (2) the importance of recognizing that serology tests for syphilis infection can be
nonreactive in a small percentage of patients with HIV. The FTA-Ab serologic test had been previously
reported as 100% sensitive in patient with secondary syphilis (USPSTF 2004), but was nonreactive while
the patient was exhibiting symptoms of secondary syphilis. Repeated serological tests for syphilis may
be needed to confirm or exclude syphilis infection in this patient population. A delay in the diagnosis of
ocular syphilis and the failure to treat can result in vision loss. Therefore, a high index of suspicion for
syphilis should be maintained in HIV/AIDS patients and empiric treatment should be considered.
357

NEVADA POSTER FINALIST - CLINICAL VIGNETTE Jason W Suszko, MD
Ascites in Pregnancy: from Erythema Nodosum to Peritoneal Coccidioidomycosis
Jason W Suszko, M.D. Whitney Shofner B.A., Reza Vaghefi, M.D., Mahendran Jayaraj M.D., Jitendra
Adepu, M.D., Nicole Davey, M.D.
INTRODUCTION: Coccidioides immitis is a soil-dwelling, dimorphic fungus endemic to the
southwestern United States, especially California’s San Joaquin Valley and Arizona. The clinical
manifestations are heterogeneous and range from asymptomatic to San Joaquin Valley Fever, and rarely
to dissemination. Traditional risk factors for dissemination include immunosuppressive therapy,
HIV/AIDS, African-American and Filipino ethnicity, and pregnancy.
CASE PRESENTATION: A 39-year-old African-American female gravida 10 para 6-0-3-6 at 24 weeks
gestation was admitted with minimal abdominal pain, large ascites, and no respiratory complaints. She
was sent from the obstetrics clinic for her ascites and had a paracentesis performed in the hospital.
Serum-ascites albumin gradient was 0.9 and clear fluid was drained from the peritoneal cavity. Initial
work-up was unrevealing and etiology was uncertain. Patient remained on the obstetrics floor for
supportive maternal and fetal care. Upon further history, patient was noted to have a cough productive
of white sputum and subjective fevers before presenting to the hospital. She was evaluated in California
in the beginning of her pregnancy for a “rash” and “pneumonia-like illness.” The rash was consistent
with erythema nodosum and her coccidioides titers were positive. Patient did not follow up for
treatment. Initially the etiology of our patient’s ascites remained unclear. However, after we obtained
old medical records and a thorough history, coccidioides serology was ordered and both IgM and IgG
were elevated. Patient was diagnosed with disseminated coccidioidomycosis in pregnancy with a history
of erythema nodosum. Patient was started on fluconazole and ascites progressively decreased.
DISCUSSION: This case illustrates the variation that can be seen in disseminated coccidioidomycosis.
Patients with dissemination rarely present with peritoneal involvement and ascites as our patient did. In
addition, her history of erythema nodosum generally favors a better prognosis and decreases the risk of
dissemination. This case is an atypical presentation of disseminated coccidioidomycosis and documents
a patient with erythema nodosum in pregnancy who then developed disseminated
coccidioidomycosis. In our clinical practice, this case will reinforce the importance of obtaining an
excellent history and skin exam as well as strengthen our clinical judgment.
358

NEVADA POSTER FINALIST - CLINICAL VIGNETTE Reza Vaghefi-Hosseini, MD
A Case of Proliferative Glomerulonephritis with Monoclonal IgG Deposits
Reza Vaghefi-Hosseini, MD Second Authors: Amarnathreddy Annapureddy, MD, Sandhya Wahi-Gururaj,
MD
INTRODUCTION: Proliferative Glomerulonephritis with Monoclonal IgG Deposits (PGNMID) is a novel
form of glomerulonephritis that has been described within the last ten years and is related to
monoclonal IgG deposition which could not be assigned to any of the established categories of
glomerular involvement by dysproteinemia (type 1 cryoglobulinemia, light and heavy chain deposition
disease (LHCDD), and immunotactoid glomerulonephritis). This entity is rarer than other forms of
dysproteinemia-related renal diseases, and may pose diagnostic challenges in renal biopsy
interpretation. We describe a case of PGNMID below.
CASE PRESENTATION: A 60 year-old white female with history of hypertension, COPD, and hepatitis C
infection presented to the ER complaining of generalized weakness and swelling of the lower extremities
for the past 2 months. On examination, the patient’s blood pressure was elevated, her lung exam
revealed diffuse wheezing bilaterally, and bilateral 2+ lower extremity pitting edema. Laboratory studies
were significant for anemia, hypoalbuminemia, renal insufficiency (Creatinine: 5.6 mg/dL), nephrotic
range proteinuria (Uprot / Ucreat =13.42) and hematuria. The patient was admitted with a diagnosis of
acute kidney injury. Ultrasound of the kidneys revealed normal sized kidneys without hydronephrosis.
Urine immunofixation revealed increased total protein without any heavy or light chain. Serum
immunofixation was negative for M-Spike with normal immunoglobulin levels. Further evaluation
including autoimmune studies ANCA, anti GBM antibody, ASO titer, and bone marrow biopsy were all
normal. Pathology from her kidney biopsy revealed: “proliferative glomerulonephritis with monoclonal
IgG with approximately 70% crescents formation”. During the hospital course, the patient’s renal
function worsened and she ultimately required hemodialysis.
DISCUSSION: Pathogenesis of PGNMID is not well known. The absence of underlying diseases including
hematologic malignancies and the light-chain and heavy-chain subclass restriction argue against antigenantibody
immune complex deposition. Furthermore, most patients do not develop detectable M protein
during long term follow-up.
Histologically, PGNMID mimics immune-complex type glomerulonephritis on light microscopy and
electron microscopy, however, by immunofluorescence, the glomerular deposits are monoclonal,
staining for a single light-chain isotype and a single heavy-chain subclass. The disease affects adults and
is more common in white and female individuals. Most patients present with nephrotic-range
proteinuria and hematuria with or without renal insufficiency. Prognosis is variable, with nearly one
quarter of patients progressing to ESRD within 2-3 years. Treatment is not well established.
This case presents a rare and novel form of glomerulonephritis with unknown pathogenesis and
challenging pathologic findings. There are very few case reports and case series in the literature with the
same characteristic as our patient. Moreover, the treatment options are not well studied. Clinicians
should be aware of this entity as a new class amongst the renal diseases associated with monoclonal
gammopathy.
359

NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE William A
Hammond, MD
Chapter Winning Abstract
W. Adam Hammond, MD
INTRODUCTION:Purpuric skin lesions are a relatively infrequent presentation to primary care clinics
and emergency departments and the differential is broad, including many potentially life-threatening
diagnoses. It is important for the clinician to have a framework for excluding serious conditions and
appropriately initiating a work-up to narrow the differential in an efficient manner. Antiphospholipid
antibody syndrome, a somewhat newly recognized condition, should be included as a cause of purpura.
CASE PRESENTATION: A 59 year old woman with fairly insignificant past history aside from mild
psoriasis and osteoarthritis presents to the Emergency Department (ED) with complaint of black lesions
on her left forearm, both thighs, and right breast. The lesions started about three weeks prior as a single
round, black, non-ulcerative lesion on her left forearm that was only mildly painful on palpation. This
resolved over a few days and two weeks later, a colleague noted an erythematous, well-circumscribed
lesion on her right face consistent with erysipelas. She visited her PCP and was started on a course of
levofloxacin for erysipelas. The next day, she noticed multiple small black lesions which started about
the size of a fingernail but grew to up to six centimeters over the next day. They were neither painful
nor pruritic, however appeared concerning and prompted evaluation in an ED. She was evaluated by
Dermatology and transferred to the nearby tertiary care hospital for definitive evaluation. Initial exam
revealed normal vital signs and unremarkable physical exam aside from round, well-demarcated deep
purple to black lesions with slight central necrosis, from three to six centimeters in largest diameter.
They were again not painful. Initial laboratory workup revealed normal complete blood counts,
complete metabolic panel including liver tests, coagulation studies, and urinalysis. Skin biopsy was
obtained. Autoimmune labs revealed mildly positive antinuclear antibody at 1:80 with weakly positive
anti-double stranded DNAat 1:10. Peripheral antinuclear cytoplasmic antibody was positive, however
myeloperoxidase antibody was negative. Anti-streptolysin-O antibody returned largely elevated. Skin
biopsy returned showing intravascular thrombosis with no evidence of vasculitis. D-dimer returned
elevated and a thrombosis panel was sent which returned negative except mild elevation of fibrinogen
and activated protein C resistance. Lupus anticoagulant and beta-2 glycoprotein-1 IgG and IgM were
negative, however anti-cardiolipin IgG returned moderately positive. The patient remained quite stable
without any additional symptoms and was discharged after three days in the hospital for this evaluation
with the diagnosis of Streptococcus induced antiphospholipid antibody formation. Subsequent testing
more than three months after discharge revealed negative antibodies.
DISCUSSION: The work up of purpuric skin lesions can typically be completed in the outpatient setting
but requires that serious causes be ruled out rapidly. In order to do so, a physician must have an
understanding of clinical indicators which portend a dangerous prognosis. History will give much of the
information and may include recent initiation of medications or recent illness. Febrile patients must be
considered for thrombotic thrombocytopenic purpura or hemolytic uremic syndrome in the right clinical
setting. Review of systems and exam should be complete including mental status and thorough skin
evaluations. Labs including complete blood counts for platelets, coagulation studies, and complete
360

metabolic panel to investigate the liver and kidney for evaluation for end organ damage are a critical
early step in the evaluation. Skin biopsy should be performed early in order to differentiate between
vasculitic, necrotic, or thrombotic lesions. A patient with low platelets or abnormal coagulation studies
may warrant admission for monitoring while further evaluation is continued. The patient in the clinical
presentation had extensive laboratory work-up which could potentially have been truncated if early skin
biopsy was performed, as work-up for vasculitis could have ended at that point. The diagnosis of antiphospholipid
antibodies induced by erysipelas was presumptively made, however definitive diagnosis of
antiphospholipid antibody syndrome requires persistence of antibodies after at least twelve weeks. This
was tested after discharge and revealed negative antibodies indicating a transient nature to their
presence in this case.
361

NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE Sung-hee Choi, MD
IMMUNE(IDIOPATHIC) THOMBOCYTOPENIC PURPURA IN SOLID TUMORS, AN UNDERREPRESENTED
PARANEOPLASTIC PHENOMENON?
Sung-hee Choi, MD
INTRODUCTION: Immune(Idiopathic) thrombocytopenic purpura (ITP) is a rare cause of
thrombocytopenia in solid tumors. There have only been scant case reports indicating an association
between solid tumors (especially, breast and lung) and ITP. Whether ITP has an established
paraneoplastic phenomenon with a predictive or prognostic value in solid tumors remains a question.
CASE PRESENTATION: A 66-year-old woman was admitted to the hematology service for management
and treatment of profound thrombocytopenia. This was noted on pre-operative screening workup for
surgical excision of a recently diagnosed localized invasive melanoma. Patient had noticed easy bruising
over the course of a year. She denied history of bleeding, initiation of new medications or
recent illness. Past medical history was significant for hypertension, non-insulin dependent diabetes,
hyperlipidemia, rheumatic fever as a child, newly diagnosed invasive localized melanoma along the
posterior neck and remote history of pulmonary embolism associated with use of contraceptives twenty
years ago. She was a previous heavy smoker with occasional alcohol use. Family history was significant
for hypertension, hyperlipidemia, colon cancer and pancreatic cancer. Upon admission, blood pressure
was significantly elevated with remainder of vital signs within normal limits. Physical examination
showed significant petechiae along the posterior oropharynx, anterior aspects of the shins and upper
extremities with scattered ecchymosis, diffuse systolic murmur and crackles auscultated along the right
lung base. There was no evidence of active bleeding.
Complete blood count showed a marked thrombocytopenia with a platelet count of 4x10(3)/mcL. There
was no evidence of a leukoerythroblastic reaction; white blood count (WBC) and hemoglobin were
normal. Laboratory workup included a negative anti-nuclear antibody without evidence of disseminated
intravascular coagulopathy or hemolysis. Thyroid studies and viral studies including human
immunodeficiency virus screening, cytomegalovirus, parvovirus, epstein-barr virus were all negative.
Peripheral smear results showed thrombocytopenia with normal-appearing neutrophils and
erythrocytes.
Treatment was initiated with intravenous immunoglobulins and a seven week course of steroid taper .
There was complete normalization of platelet counts. However, as part of a complete staging workup for
melanoma during hospitalization, CT scan of the chest showed a 5.8 x 5.9 cm peripherally enhancing,
centrally necrotic, lobulated right hilar mass with peripheral collapse of the right middle lobe and
surrounding interstitial thickening worrisome for lymphangitic involvement. This mass was later
confirmed to be adenocarcinoma of the lung. Patient subsequently underwent resection of the involved
portion of the lung without evidence of recurrent ITP.
DISCUSSION: In patients with ITP and cancer, cancer-related ITP needs to be considered. However,
limited evidence exists for an extensive investigation for a present or future cancer unless there is high
suspicion of malignancy. The possibility of paraneoplastic autoimmune thrombocytopenia in
solid tumors may provide further guidance into future immune based therapy.
362

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Nayan K Desai, MD
Toxicity from 33rd element of periodic table- The Hair spoke the truth.
Nayan Desai Menon Divya, Harooz Rachel and Gable Brian
INTRODUCTION: Arsenic is one of the oldest poisons known to man. Its applications throughout history
are wide and varied, as it has been used in poisons, make-up, paint and pesticide. The following case
report describes a Pakistani male who presented with subacute bilateral progressive ascending
polyneuropathy with respiratory failure and pancytopenia. On subsequent evaluation his condition was
attributed to arsenic, as high levels were present in both hair and urine.
CASE PRESENTATION: A 23 years old Pakistani male presented with a 3-week history of bilateral lower
limb paraesthesias. On examination he had absent ankle reflexes with significant sensory deficits to all
modalities below the knees. His complete blood count showed pancytopenia. During the hospital course
he developed progressive ascending weakness of the lower extremities, which then spread to upper
extremities over 3 days. He subsequently developed type 2 respiratory failure requiring intubation and
mechanical ventilation. Nerve conduction studies were consistent with sensorimotor axonal
polyneuropathy. An extensive investigation for rheumatologic disorders, familial amyloidosis,
porphyrias, hepatitis, lyme disease, vitamin deficiencies and Gullian barre syndrome were negative.
Bone marrow aspirate with biopsy for the pancytopenia showed severely dysplastic erythropoiesis and
megakaryopoesis. The differential diagnosis at that time was narrowed down to heavy metal
intoxication. On further inquiry it was found that patient experienced the onset of these symptoms after
returning from Pakistan four months prior to presentation. Segmental Hair analysis by mass
spectroscopy was positive for arsenic in all 7 segments of the hair sample. This represented exposure
over a period of more than three months assuming the rate of hair growth is 1.25 cm/month. Urinary
arsenic levels were elevated. Marked improvement in clinical features were noted after chelating with
dimercaprol for 48 hours followed by oral succimer. A detailed investigation was done for source of
arsenic, but no source was found. A hypothesis of possible arsenic ingestion from unani medicine for
depression during his stay in Pakistan was postulated but never confirmed.
DISCUSSION: Arsenic toxicity is a global environmental health problem, affecting millions of people.
Arsenic induced genotoxicity involve an alteration of the integrity of the cellular genetic material by
oxidants or free radical species. Acute arsenic poisoning is easily confused with acute diarrhea
associated with cholera. Chronic arsenic intoxication may lead to severe multisystem illness as seen in
this patient and may involve the integumentary, hematological, cardiovascular and peripheral nervous
systems. The neuropathy is primarily due to destruction of axonal cylinders and compositional changes,
leading to axonopathy.
This case highlights importance of suspecting heavy metal intoxication in patients with multisystem
illness that is not consistent with an alternative classical disease presentation.
363

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Parag A Chevli, MD
A rare cause of acute coronary syndrome: Spontaneous coronary dissection
Parag A Chevli, MD Additional authors: Srihari Penkulinti, Kelash
INTRODUCTION: CASE PRESENTATION: A 37 year old Latino female presented with midsternal and
left sided chest pain started 2 days prior to admission. She described the pain as pressure like, 9/10 in
intensity, intermittent, radiating to back, relieved by rest, not associated with exertion or food intake.
The pain was associated with shortness of breath, palpitation and light headedness. She denied any
history of recent travelling or use of birth control pills. Her past medical history was significant for
depression diagnosed 2 years ago for which she was taking citalopram, buspirone and trazodone. She
had regular monthly periods and denied any recent pregnancy. (G1P1A0). There was no family history of
early/sudden cardiac death. She denied any toxic habits. On examination vitals were stable and physical
examination did not reveal any abnormalities. The electrocardiogram(ECG) revealed Q waves in lead II,
III, aVF, V4-V6. The cardiac troponin I was 0.06(Normal range

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Tatiana Gandrabura, MD
Recurrent Cushing
Tatiana Gandrabura, MD Rendy Tomasulo,MD Intekhab Ahmed,MD, FACP
INTRODUCTION: Cushing syndrome and Cushing disease are rare but well-established endocrine
entities. We present a case where our patient had both conditions over a 9-year period.
CASE PRESENTATION: In 2003 a 35-year old female with recent history of weight gain, abdominal
striae, easy bruising and abdominal pain underwent an abdominal CT which showed a left-sided adrenal
adenoma measuring 2.5 cm. Work-up to assess the functionality of the adenoma revealed an AM
cortisol of 30.9 mcg/dL, cortisol of 22 mcg/dL after a 1-mg overnight dexamethasone suppression test
(DST), a 24-hour urinary free cortisol (UFC) of 1500 mg/dL and an ACTH of 213 pmol/L. Magnetic
resonance imaging (MRI) of the pituitary revealed a 7-mm right-sided pituitary mass. She underwent
transphenoidal removal of her pituitary microadenoma with a dramatic fall in cortisol level to 2 mcg/dL.
She remained in remission until 2011 when her symptoms recurred. Further testing revealed AM cortisol
of 24 mcg/dL, cortisol of 20 mcg/dL after 1-mg DST, 24 hour UFC of 455 mg/dL, and an undetectable
ACTH on more than three occasions. Computed tomography of her adrenals showed a left-sided
adrenal adenoma of 3.4 cm. MRI of the pituitary was unremarkable. She underwent left adrenalectomy
with normalization of her biochemical and phenotypic appearance. She is stable on 15mg of prednisone
since her surgery.
DISCUSSION: Our case illustrates a very rare presentation of recurrent hypercortisolism initially caused
by Cushing disease followed by recurrence of hypercortsolism due to Cushing Syndrome.
Cushing disease and Cushing syndrome are well-documented entities; their true incidence remains
imprecise due to the rarity of their occurrence. In addition, there is only one case in literature where
both entities were present in the same patient. ACTH-dependent Cushing disease is 5-6 times more
common than ACTH-independent Cushing syndrome.
Most cases of hypercortisolism have well-established signs and symptoms. Rarely, sudden onset of
diabetes, easy bruising or osteoporotic fracture in a young patient may lead to the diagnosis. Gradual
onset of central obesity, moon facies, buffalo hump, proximal muscle weakness and atrophy gives the
appearance of “lemon on match sticks”. Easy bruising and purple striae on the abdomen and inner
thighs are pathognomonic of hypercortisolism.
Diagnosing hypercortisolism is a daunting task. After excluding exogenous glucocorticoid exposure, the
first step is to establish hypercortisolism by 24-hour UFC measurement (most common) or by 1-mg DST.
To differentiate Cushing Disease from Cushing syndrome, an elevated ACTH level favors a pituitary
etiology or ectopic ACTH source, while a suppressed ACTH level favors an adrenal source of
hypercortisolism. Pituitary MRI helps localize a microadenoma while abdominal computed tomography
helps localize adrenal adenomas. For ectopic source of ACTH, chest computed tomography is the initial
investigation. Surgical cure is the best option in majority of hypercortisolism cases.
365

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Tatiana Gandrabura, MD
Sacral insufficiency fractures.
Tatiana Gandrabura, MD Randy Tomasulo,MD Intekhab Ahmed,MD,FACP
INTRODUCTION: Sacral insufficiency fractures (SIFs) generally occur in postmenopausal patients with
osteoporosis, those who are undergoing radiation therapy for treatment of pelvic malignancy or in
patients treated with high doses of corticosteroids. We report a case of SIFs in a young female.
CASE PRESENTATION: An 18-year old white female, no prior health issues, presented with low back
pain for six months. Initially the pain was only present during exercise, but eventually it occurred while
walking, rising from chair and rolling over in bed at night. There was no history of physical trauma or
family history of any skeletal or systemic disorder. She denied alcohol or illicit drug use. Her dairy
consumption was adequate. Her menarche began at age 13 with regular menses and no pregnancies.
On examination her height was 5’ 3”, weight 123 pounds with fair skin. No kyphosis or lordosis was
noted. She reported pain on sitting, rising from a chair, and standing with worsening of pain by lumbar
flexion. Her neurological exam for muscle strength and deep tendon reflexes was normal. Serum
calcium was 9.8 mg/dL, intact PTH was 15 pg/mL, 25-hydroxy Vitamin D was 32ng/dL, albumin was 3.9
g/dL, TSH was 1.7 uIU/mL, Complete blood count, renal and hepatic function tests were normal. No
osteopenia or compression fractures were seen on lumbar spine radiographs.
Magnetic resonance imaging of the hips showed areas of marrow edema within the sacral wings, the
distribution and appearance of which was consistent with bilateral SIFs. Bone densitometry using
pediatric software showed lumbar bone mineral density Z-score of minus 2.1.
DISCUSSION: SIFs are a form of stress fractures caused by normal stress applied to bone with deficient
elastic resistance. Osteoporosis is the most important cause of SIFs, followed by high dose steroid
therapy. Low back and buttock pain exacerbated by movement is the most common presentation.
Patients may also have other fractures such as pubic ramus fracture. A technetium-99 bone scan may
show the classic “H” or “Honda” sign representing combined bilateral vertical and horizontal sacral
fractures in 15–68% cases. Magnetic resonance imaging demonstrates bone marrow edema. Computed
tomography of the lumbar spine is considered the gold standard for diagnosis. Evaluation includes
serum 25-hydroxy vitamin D, calcium levels, and work-up for secondary causes of osteoporosis. Bed rest
in the acute phase (up to 72 hours) is often recommended, though there is beneficial evidence of early
mobilization. Acetaminophen and anti-inflammatories are used for pain. Older patients may benefit
from bisphosphonate use. Calcium and vitamin D supplementation is recommended along with
pharmacotherapy. Sacroplasty may be an option for relief of chronic pain.
366

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vipin Mittal, MBBS
Sarcoidosis: not always restrictive!
Vipin Mittal, MBBS Co-Authors: Anery Patel, MD Medhat Ismail, MD.
INTRODUCTION:Sarcoidosis is a multisystem granulomatous disorder of unknown etiology that is
characterized pathologically by the presence of non-caseating granulomas in involved organs. It initially
presents with either bilateral hilar adenopathy or pulmonary reticular opacities or skin, joint and/or eye
lesions. Pulmonary function tests characteristically reveal a restrictive pattern with a reduction in the
diffusing capacity for carbon monoxide, although it is not unusual for lung function to be normal.
CASE PRESENTATION: 47 year old African-American female who has past medical history significant
for COPD, severe pulmonary hypertension with pulmonary arterial pressure of approx. 87mm Hg with
resultant right sided heart failure, cirrhosis of liver, and ascites presented in Emergency room with
progressively worsening cough, shortness of breath for 2 weeks. (The symptoms of mild cough and
shortness of breath were present for almost two years.) She has been on spironolactone, furosemide,
digoxin, baby aspirin and fluticasone inhaler at home. She denied smoking, alcohol, illicit drug use and
occupational exposures. She had temperature of 97 F, pulse rate of 94 bpm, blood pressure of 115/87
mmHg, and respiratory rate of 18 per minute. On physical exam she had distended neck veins,
diminished vesicular breath sounds, bilateral scattered rales, normal S1 and accentuated S2, distended
abdomen, ascites, firm liver and minimal edema in bilateral lower extremities. Laboratory data
was significant for mild anemia, elevated B type natriuretic peptide level (1910 pg/ml; normal range 0-
100). Serum chemistry, alpha 1 antitrypsin, ACE (angiotensin converting enzyme) level was normal. HIV
& Hepatitis profile was negative. Chest radiograph showed chronic fibrotic changes with hyperinflation.
CT scan of the chest revealed diffuse emphysematous changes, retico-nodular fibrotic changes in
bilateral upper lobes. Patient was admitted and started on sildenafil and diuretics and intravenous
solumedrol. Pulmonary function tests revealed low FEV1 (34% of predicted), low FVC (55% of predicted)
with a moderate reduction in FEV1 /FVC ratio (63% of predicted) consistent with obstructive
pattern. Residual volume was estimated to be very high (115%). Diffusion capacity was also found to be
severely reduced (30% of predicted) consistent with severe pulmonary hypertension and radiological
findings. Video assisted thoracic surgery (VATS) for lung biopsy was scheduled to rule out the possibility
of Lymphangiomyomatosis (LAM). The pathology revealed non-caseating granulomas in all sections of
lung biopsy with areas of atelectatic and emphysematous changes. Diagnosis of sarcoidosis was
confirmed and patient was discharged home on steroids resulting in a good response.
DISCUSSION: We present a patient who had chronic lung disease of unclear etiology that led to a
number of sequels from resultant right sided heart failure. The diagnosis of sarcoidosis can be
challenging in he absence of typical presentation. The diagnosis is based upon clinical and radiological
findings, exclusion of other diseases that may present similarly and histopathologic evidence of noncaseating
granulomas. It is rare for sarcoidosis to manifest as emphysematous changes and obstructive
pattern on pulmonary function tests. Hence, lung biopsy is the only definitive answer in such cases.
367

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vipin Mittal, MBBS
Pulsating belly from an infected heart!
Vipin Mittal, MBBS Co-Authors: Priyank Shah, MD, Anish Shah, MD, Walid J Baddoura, MD
INTRODUCTION:Mycotic aneurysm is a localized, irreversible arterial dilatation due to destruction of
the vessel wall by infection. It can develop as a complication of bacterial endocarditis and should be kept
in differential diagnosis.
CASE PRESENTATION: A 26 year-old male came to the hospital with the chief complaint of epigastric
pain of one month duration. It was sharp, constant, 9/10 in intensity, non-radiating and with minimal
relief with over the counter pain medications. He had no significant past medical or surgical history. He
has been an active intravenous heroin abuser, smoked half a pack of cigarettes per day and drank
alcohol on daily basis. On examination, he had fever (102°F), tenderness in the epigastric region and a
diastolic murmur. The diagnosis of infective endocarditis was made and he was started on broad
spectrum antibiotics. Computed tomography (CT) scan abdomen revealed splenic infarct, bilateral renal
infarcts and a bi-lobed fusiform superior mesenteric artery aneurysm (SMAA) distal to its origin
measuring about 5.7 cm in its greatest dimension. Echocardiogram showed aortic valve vegetation
measuring 4.4 x 1.1 cms with severe aortic valve regurgitation. Blood cultures grew Enterococcus
faecalis group D organisms. The patient also developed an embolic stroke involving the right middle
cerebral artery and had left-sided hemiplegia. Subsequently, he complained of worsening abdominal
pain and on examination had a pulsatile swelling in the epigastrium. Repeat CT scan of the abdomen
showed increase in the size of the superior mesenteric artery aneurysm measuring 7.6 x 6.7 x 7.6 cm. An
aortogram was obtained which showed a pseudoaneurysm involving superior mesenteric artery beyond
jejunal and ileal branches and measured about 9 cm. Ultrasound guided fibrin injection of the aneurysm
was tried with only partial thrombosis. Eventually, the patient went for exploratory laparotomy and
ligation of the pseudoaneurysm. He also underwent aortic valve replacement and was discharged to a
rehabilitation center.
DISCUSSION: Mycotic aneurysm can develop following bacterial infection of a previously normal
arterial wall or through secondary infection of a preexisting aneurysm. This case illustrates development
of mycotic aneurysm as a complication of bacterial endocarditis. Possible mechanisms include occlusion
of vasa vasorum or entire arterial lumen by tiny septic emboli, damaging the muscular layer of the
vessel, and subsequent intra-arterial pressure causing dilation and aneurysm formation. SMAAs have a
definite rupture risk and high resultant mortality. Early recognition of this complication is important for
appropriate treatment and prevention of further complications.
368

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Ronald E Pachon, MD
SUDDEN CARDIAC DEATH AS A PRESENTATION OF ANOMAOLUS ORIGIN OF THE LEFT CORONARY
ARTERY FROM PULMONARY ARTERY IN A YOUNG ADULT
Ronald E Pachon, MD Co-Authors: Mark Niemiera, MD, FACC; Constante Gil, MD FACP; Shuvendu Sen,
MD; Vishwanath Pattan, MD; Kebir Bedran, MD; Fowad Shahzad,MD
INTRODUCTION: Sudden cardiac death in itself is a rarity in young adults in the absence of
hypertrophic cardiomyopathy. Congenital cardiac anomalies presenting as sudden cardiac death in
adulthood without any preceding symptoms in childhood are extremely rare (1). We report a case
of sudden cardiac death as the first presentation of anomalous origin of the left coronary artery from
pulmonary artery (ALCAPA) in a young female with no history of hypertrophic cardiomyopathy.
CASE PRESENTATION: An 18 year-old apparently healthy and physically active female, who was last
seen competitively running 4 min prior, was found to be unresponsive. A paramedic at the site, who
found her pulseless, performed CPR until EMS team cardioverted and intubated her on arrival 5 min
later. In the ED vital signs revealed BP: 126/100 mmHg, HR: 172 BPM, RR: 20/min, Tº: 98.7ºF. Her family
reported a flu-like illness one week before admission but denied any episodes of cyanosis, palpitation,
joint swelling or skin lesions in the remote past. They denied patient history of trauma, recent travel,
smoking, drugs, alcohol, medication use or any family history of sudden cardiac death. On examination
the patient was intubated and appeared pale without cyanosis, JVD, or carotid bruit; she had regular
heart sounds with no murmur, rub or gallop. The rest of physical examination was unremarkable. ECG
showed sinus tachycardia with T wave inversions in leads I, aVL and V1-V4, QTc 421 ms; CXR showed no
evidence of pneumothorax, enlarged mediastinum or pleural effusion. Chest CT angiogram did not
reveal any evidence of pulmonary embolism. Head CT scan showed no evidence of hemorrhage. Urine
drug and pregnancy screens were negative. CBC and metabolic panel were within normal limits.
Complement levels were normal. Serial troponin I (0.36, 7.39) and CKMB (5.69, 216) were elevated.
Echocardiography showed severely impaired EF (20%) with a hypokinetic LV without any evidence of
significant valvular or hypertrophic heart disease. She was immediately transferred to a tertiary center
for cardiac catheterization which showed ALCAPA. Unfortunately the patient had irreversible brain
damage due to anoxic encephalopathy and no further intervention was pursued.
DISCUSSION: The patient had collateral circulation from her RCA to LAD which likely enabled her to be
physically active without any symptoms until the day of presentation. This clinical case illustrates the
need for early consideration and recognition of ALCAPA in otherwise healthy young individual, who
presents with sudden cardiac death.
369

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Imran A Shaikh, MD
A ‘fahr’ Fetched Diagnosis
Imran A Shaikh, MD Additional Authors: NAYAN DESAI MD ; ANERY PATEL MD ; IBRAHIM KHADDASH
SALEH MD
INTRODUCTION:Seizure Disorder has varied differential diagnosis. But when it is combined with a
specific electrolyte abnormality and a specific computed tomography finding, then the diagnosis
narrows down to a few rare causes. In this case report we present to you a case of seizure disorder with
underlying pseudohypoparathyroidism in a patient of Fahr’s Syndrome.
CASE PRESENTATION: 18 year old Indian female presented with 3 episodes of generalized tonic clonic
seizures over the preceding 24 hours. On further inquiry patient’s family observed that she had been
drowsy, had multiple episodes of vomiting and was extremely lethargic since 10 days. She had a history
of Seizure disorder, which was diagnosed 4 years prior to presentation and was refractory to medical
therapy with phenytoin, phenobarbitone and valproic acid for the same. She denied any history of
recent trauma to the head, fever or photophobia.
On examination, she was afebrile with a heart rate of 94 bpm, blood pressure of 120/84 mm of mercury.
On Central nervous system examination patient was drowsy, responding to painful stimuli. Deep tendon
reflexes were 3+ in all extremities. Examination of the other systems was essentially within normal
limits. Investigations were suggestive of hypocalcemia (Ca-6.5 mg/dl) and hyperphosphatemia
(Phosphorus- 6.1 mg/dl). Her renal function test, liver function test and 25 Vitamin D levels were within
range. Computerised tomography scan of the head showed diffuse calcification of the Basal Ganglia
bilaterally. Parathyroid hormone levels were elevated. So a diagnosis of Fahr’s syndrome with
pseudohypoparathyroidism was made. Patient was started on oral calcium supplementation along with
calcitriol. Patient calcium and phosphorus normalized after 4-6 weeks of treatment and patient
remained symptom free.
DISCUSSION: Fahr's Syndrome is a rare, genetically dominant, inherited neurological disorder
characterized by abnormal deposits of calcium in areas of the brain that control movement, including
the basal ganglia and the cerebral cortex. Symptoms of the disorder may include deterioration of motor
function, dementia, seizures, headache, dysarthria, spasticity.Age of onset is typically in the 40s or 50s,
although it can occur at any time in childhood or adolescence. When it is associated with
pseudohypoparathyroidism, management will mainly be focused towards optimizing Serum Calcium
levels towards with the help of Calcium, Vitamin D supplements and Calcitriol.
370

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Imran A Shaikh, MD
Deadly Duo : Disseminated Histoplasmosis And Hiv
Imran A Shaikh, MD Additional Authors :NAYAN DESAI MD ; MICHAEL LANGE MD ; MATTHEW GRANT
MD
INTRODUCTION:Oral ulcers are common in HIV patients, differential of which varies from viral,
bacterial, fungal, mycobacterial to neoplastic causes.In some countries other than the United States,
although definite sub-typing based on geography for fungal infection is lacking, fungal infections are
indeed common opportunistic pathogens in AIDS patients. The purpose of this case is to sensitise
physicians towards fungal infections to be considered as a part of the differential diagnosis in immigrant
populations of AIDS patients who present with clinical features of fever, lymphadenopathy and weight
loss.
CASE PRESENTATION: A 28 year old married male from India presented with painful ulcer at the left
angle of his mouth present for 2 months which resulted in severe pain on deglutition.The ulcer gradually
increased in size and spread over the left buccal mucosa. Patient also noticed a progressive enlarging
swelling in the left submandibular region.He complained of low grade fever, loss of appetite and weight
loss of 6 kg in the preceding 2 months.
On inquiry, patient was known to be HIV 1 positive for the past 1 year and not on any antiretroviral
drugs. Patient was started on antitubercular 4 drug regimen for last 1 month after fine needle aspiration
cytology of left submandibular swelling from a different hospital.However patients symptoms continued
to worsen inspite of being on treatment.
On examination, weight was 49 kg with poor nutritional status, oral temperature of 37.8 C, pulse of 130
bpm and blood pressure of 110/74 mm of mercury. Local examination revealed an irregular tender,
indurated ulcer at left angle of mouth covered with pus and slough. Left submandibular lymph node was
discrete 3 X 3 cm tender, firm and freely mobile.No axillary and inguinal lymphadenopathy.Nontender
hepatosplenomegaly was present.
Scrapings were taken from the oral ulcer and a biopsy of submandibular swelling was performed.
Histopathological examination of stained smear showed epitheloid granulomas with intracellular
granules classic of Histoplasma capsulatum. Special stain with Gomori methnamine silver stain
confirmed the findings.
A diagnosis of AIDS with disseminated histoplasmosis was made.Antitubercular drugs were stopped and
patient was started on intravenous amphotericin B for 25 days followed by maintainence therapy with
itraconazole for 12 weeks. Marked clinical improvement along with reduction in ulcer size by 70% was
noted.
DISCUSSION: This case highlights the fact that although tuberculosis is the most common opportunistic
pathogen in AIDS patients in developing countries and immigrant populations,fungal infections like
histoplasmosis share many clinical features with constitutional symptoms,lymphadenopathy and
multiorgan involvement and hence should always be included in the differential diagnosis.
Demonstration of organisms in biopsy samples are crucial in the confirmation of a definitive diagnosis
and treatment.
371

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Yue Cindy Wang
Persistent Vertigo As A Presentation Of Pulmonary Leptomeningeal Carcinomatosis
Yue Cindy Wang, MD, Brain H Kim, MD
INTRODUCTION: Leptomeningeal carcinomatosis (LMC) is an uncommon manifestation of metastatic
lung cancer. The overall incidence reported is 3-8%. Diagnosis is often difficult to establish. We report
a rare case of LMC from recurrent lung cancer that presented initially with persistent vertigo.
CASE PRESENTATION: A 73-year-old female presented to the emergency room with persistent
vertigo. One month prior to this admission, she developed sudden onset of vertigo associated with
nausea, bilateral tinnitus and some unsteady gait. Patient came to ER twice and was admitted to the
hospital on the 2 nd visit. Physical examination and laboratory tests were essentially normal. Brain CT,
MRI and MRA showed no evidence of stroke, mass or vascular insufficiency. She was diagnosed with
peripheral vertigo and discharged with meclizine and methylprednisolone. However, her symptoms
persisted. She was referred to ENT and the examination was negative. Patient returned with
unresolving vertigo and new-onset dysphagia. Her past medical history is significant for early stage lung
adenocarcinoma diagnosed in 2006. She had left lower lobectomy without chemotherapy or
radiotherapy. She followed up with her oncologist every three months and there was no clinical or
imaging evidence of recurrence. Patient was readmitted for further investigation. Physical examination
and laboratory tests were unremarkable. A barium esophagogram done to evaluate the patient for
dysphagia was noncontributory. A repeated brain MRI, however, demonstrated innumerable foci of
leptomeningeal carcinomatosis involving cranial nerves V, VIII, and XII. CSF cytology was sent and
positive for marked atypical cells, consistent with metastatic adenocarcinoma. CT chest revealed
conglomerate mediastinal adenopathy with the largest measuring 1.7cm. Ultrasound guided FNA of a
mediastinal node confirmed lung adenocarcinoma. Patient deferred further treatment and was
discharged to hospice.
DISCUSSION: LMC is characterized by a diffuse infiltration of neoplastic cells to the
leptomeninges. The clinical presentation is heterogeneous with involvement of cerebrum, cranial
nerves and spinal cord. Diagnosing LMC can be challenging. MRI, commonly regarded as the imaging
study of choice, has a sensitivity of 66-77%. Cytology of CSF is the gold standard, but still misses about
10% of the cases. The prognosis of LMC is dismal. Early diagnosis and therapy is crucial to preserving
neurological function, relieving symptoms and improving survival. Currently, intrathecal chemotherapy
remains the mainstay of treatment although survival benefit is still in debate.
Isolated vertigo is an unusual presentation of LMC, not necessarily associated with a known history of
malignancy. In our case, the nonspecific symptoms, normal physical and initial negative imaging led to a
delay in doing CSF cytology. A high index of suspicion and early CSF analysis are warranted for accurate
diagnosis.
372

NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Sumeja Zahirovic, MD
Vibrio Vulnificus infection in New Jersey after Hurricane Irene
Sumeja Zahirovic, MD Authors: Min J. Kim, MD, Harry A. Roselle MD, FACP
INTRODUCTION: Vibrio Vulnificus is a gram-negative bacillus inhabiting warm salt water environments.
Infection occurs by ingestion of uncooked seafood, or exposure of skin wound to infected waters.
Patients with liver disease, depressed immune response, and hemochromatosis are at a particular risk of
developing the infection with necrotizing fasciitis and septic shock. The presence of shock increases
mortality to greater than 50%. The majority of the cases occur in the Gulf Coast states. According to
New Jersey Department of Health and Senior Services (NJDHSS), approximately 12 cases of non-cholera
vibriosis are reported annually in New Jersey. We present a patient with Vibrio Vulnificus infection, who
frequented the beach of Jersey shore as a runner.
CASE PRESENTATION: An 82-year-old runner with psoriatic arthritis on prednisone presented with
severe right lower extremity pain and swelling. He developed nausea, vomiting and lethargy, which
prompted his family to bring him to the hospital. He had a fever of 100.7 F, blood pressure 72/43 mmHg,
and pulse rate 77 beats/minute. Physical examination revealed edema, erythema, warmth, tenderness,
and blisters of right lower extremity. Laboratory studies were significant for WBC 16400/uL and 7.5
mg/dL of lactic acid. The patient was transferred to ICU for septic shock secondary to presumptive
cellulitis, where he developed toxic encephalopathy and acute respiratory failure, requiring mechanical
ventilation. He received aggressive intravenous hydration, pressors, stress dose of hydrocortisone and
broad-spectrum antibiotics. His condition did not improve and he developed rhabdomyolysis, metabolic
acidosis and acute renal failure. He was taken for extensive surgical debridement from ankle to knee.
The pathology was consistent with necrotizing fasciitis. Blood and wound cultures grew Vibrio Vulnificus;
hence, empiric antibiotics were changed to cefepime, clindamycin and doxycyclin. He became
hemodialysis dependent due to renal failure with anuria. He was extubated, but still required high flow
oxygen. He developed acute gastrointestinal bleeding, and was found to have ferritin of more than
20000 ng/mL. Further workup for hemochromatosis was deferred due to his unstable condition. DNR
was requested. After about 2 weeks of ICU stay, patient had asystolic cardiac arrest. Autopsy was
refused by his family.
DISCUSSION: We report a patient with psoriatic arthritis, chronic prednisone treatment, and possible
hemochromatosis, who developed Vibrio Vulnificus septicemia at the Jersey Shore. He developed the
infection soon after Hurricane Irene. An increased incidence of Vibrio Vulnificus infection has been
reported after Hurricane Katrina secondary to flooding with infected waters. Suspicion of Vibrio
Vulnificus in New Jersey should be raised in patients with severe cellulitic features, especially following a
tropical storm, which may lead to an early diagnosis, proper management, and improved mortality.
373

NEW MEXICO POSTER FINALIST - CLINICAL VIGNETTE Jonathan Jivin Danaraj,
DO
Chapter Winning Abstract - A Malignant Metabolic Disturbance: Lactic Acidosis And Hypoglycemia In A
66 Y.O. Navajo Female.
Jonathan Jivin Danaraj, DO Second Author: Michelle Harkins, MD
INTRODUCTION: The presentation of hypoglycemia and lactic acidosis in a patient with diffuse large B
cell lymphoma is extremely rare. There are approximately 30 described cases of lactic acidosis in
association with lymphoma and fewer that include hypoglycemia. This constellation of findings leads to
a poor prognosis.
CASE PRESENTATION: A 66 y.o. female with history of DM II was transferred from an outside hospital
(OSH) to The University of New Mexico Hospital(UNMH) after ct scan to rule out pulmonary embolus
found mediastinal lymphadenopathy suspicious for lymphoma. The patient had presented to her pcp
two weeks prior with mild malaise. Labs from OSH revealed a leukocytosis of 33,000 with a lymphocyte
predominance 40% on peripheral smear, an anion gap acidosis , and hypoglycemia to 27. Initially, the
patient was mildly tachycardic but otherwise hemodynamically stable. Repeat labs confirmed the
leukocytosis with lymphocyte predominance and illustrated a mild liver failure. Specific labs included a
anion gap of 23, uric acid of 14.8, ldh of 3884, lactate of 10, potassium was 3.4, phosphate was 3.3 and
glucose of 54. A bone marrow biopsy and flow cytometry revealed atypical, CD20+ lymphocytes with
distinct vacuoles and large indented nuclei. These findings made diffuse large b-cell lymphoma most
likely. Lymph node architecture from biopsy was not possible as the patient deteriorated clinically. On
hospital day 2, the lactic acidosis had not improved and her urine output dwindled. Her pH on ABG
was 7.12. The patient’s hypoglycemia was difficult to control in the low 90’s with a d5w infusion. The
patient further decompensated requiring pressors and was intubated for respiratory
failure. Chemotherapy was initiated with cyclophosphamide and rituxan. On hospital day 3, the patient
had increased pressor requirements and further increase of lactate to 21 and an ABG pH of < 6.8. The
patient became anuric. Care was withdrawn shortly after and the pt expired.
DISCUSSION: These metabolic abnormalities when attributed to lymphoma have described mortality
rates >70% occuring within weeks to one month. These alarming statistics have some oncologists
suggesting this to be an oncologic emergency. The pathophysiology of these findings occur when there
is a high tumor burden and with diffuse infiltration of malignant cells into the liver inhibiting the cori
cycle preventing the body from eliminating lactate and creating glucose. Prompt recognition is crucial as
the rapid progression to multi-organ failure can only be prevented if the malignancy responds to
chemotherapy.
374

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Cesar Esteban Ayala-
Rodriguez, MD
Chapter Winning Abstract
Cesar E Ayala-Rodriguez Samir Garyali
INTRODUCTION: Total occlusion of the left main coronary artery (LMCA) is a rare angiographic finding
due to its catastrophic clinical presentation associated with sudden cardiac death, cardiogenic shock,
pulmonary edema or malignant arrhythmias. It has pronounced therapeutic implications with potential
need of emergent coronary bypass grafting. Despite moderate accuracy of the electrocardiogram (EKG)
to determine the anatomic location of infarction, it has the ability to discriminate among various
coronary artery obstruction patterns, ST-segment elevation (STE) in lead aVR, although frequently
overlooked it has been recognized to indicate LMCA occlusion.
CASE PRESENTATION: Case No.1: An 80 year old male presented with retrosternal chest pain,
occurring intermittently for the past 2 weeks but more frequently in the past 3 days. These episodes
would last for 20 minutes and were associated with shortness of breath.
PMHx: Three vessel CAD with PCI–RCA stenting 5 months prior and normal LVEF, systemic hypertension
and hypercholesterolemia.
PE: BP=115/75mmHg, HR=105, RR=16, Temp=98.3°F, O2Sat=100%, S1,S2 were audible, tachycardic,
regular rhythm, with no gallop or murmur. Lungs were clear and the rest was unremarkable.
Initial labs: Creatinine 1.3mg/dL, WBC 8.1/dL, hematocrit 38, platelets 277K, CK 160ng/mL and
Troponin-I 0.63ng/mL. LVEF 40%.
Evolution: Developed recurrent episodes of ventricular fibrillation and a successfully treated cardiac
arrest. After which coronary arteriography showed 99% stenosis of LMCA which was reduced to 0% after
everolimus-eluting stent placement.
Case No.2: A 59 year old female presented with retrosternal pressure-like pain, radiated to left arm, jaw
and upper back, pain persisted until ED management. Symptoms had occurred with less intensity
intermittently for the past 3 days, sometimes at rest and self resolving after minutes. Was detected with
narrow complex tachycardia to 170 bpm by EMS team.
PMHx: Diabetes mellitus type2 for 14 years, systemic hypertension and hypercholesterolemia.
PE: BP=153/69mmHg, HR=119, RR=19, Temp=98.7°F, O2Sat=92% on 4L/min. Lungs with bibasilar rales to
mid lung fields. S1,S2 were audible, tachycardic, regular rhythm, with no gallop or murmur. Rest of exam
was unremarkable.
Initial labs: Creatinine 0.7mg/dL, WBC 12.1K/dL, hematocrit 41.8, platelets 308K/dL, CK
42/1.7ng/mL and 90’ 65/5.0ng/mL and Troponin-I 0.08ng/mL and 90’ 0.29ng/mL
Chest Xray revealed bilateral pulmonary congestion, no cardiomegaly.
Evolution: Plavix withheld on initial therapy. After angiogram, on day#2 had emergent off pump
coronary bypass x2 with LIMA to LAD and reverse saphenous vein graft to OM.
375

DISCUSSION: These cases emphasize the importance of isolated STE in lead aVR. It has been
demonstrated to indicate LMCA occlusion or severe three-vessel CAD.
The distinction of acute coronary syndromes (ACS) with profound therapeutic and prognostic
implications is based on the ST-segment. It was established in early fibrinolytic trials that did not
consider isolated STE in analysis.
However the prognostic significance of this EKG finding is of great magnitude and may play a great role
on survival of patients with NSTEMI.
The incidence of LMCA occlusion in patients undergoing elective coronary angiography is 0.03-0.04%
and 0.37 to 2.96% in patients with acute myocardial infarction undergoing emergent cardiac
catheterization.
The diagnostic importance of STE in aVR in early management of ACS is heighten by the determination
of thienopyridine use due to potential emergent coronary artery bypass grafting or nowadays
revascularization by stenting.
Much more recognition and further analysis of the value of STE in aVR in management of ACS is needed
to confirm these proposals
376

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Suneesh C Anand, MBBS
Chapter Winning Abstract UNFRACTIONATED HEPARIN INDUCED SKIN NECROSIS
Suneesh Anand,Rawat N,Covalcic C, Dhanve A, Maheshwari N,C Abeddi, Matejak P, Newman T.
INTRODUCTION: Unfractionated heparin (UFH) induced skin necrosis is a rare immune complex
phenomenon associated with heparin induced thrombocytopenia (HIT) syndrome. It is seen in patients
with thrombocytopenia (more than 50% decrease) or less commonly in the presence of HIT antibodies
alone. In our patient however there was only mild thrombocytopenia (less than 50% decrease) and
serologies for HIT were negative.
CASE PRESENTATION: 54 year old female with Diabetes Mellitus and Asthma was admitted for two
day history of fever, cough and pleuritic chest pain. She was started on antibiotics for community
acquired pneumonia since chest radiograph showed bilateral infiltrates. Atypical pneumonia workup
was positive for influenza A and she was started on treated with Oseltamivir. However she continued to
be febrile and fever work up was initiated. Echocardiogram and Pan Computed Tomography was done
which was inconclusive. Venous duplex showed acute deep vein thrombosis (DVT) in both lower limbs
and she was started on UFH drip. She had already been on DVT prophylaxis with subcutaneous heparin
since admission. Within two days of UFH heparin drip, she developed skin lesions on medial aspect of
right thigh and later on both breasts. The lesions were well demarcated, hyperpigmented, purple
patches with erythematous borders. Work up for Disseminated Intravascular Coagulation,
Antiphospholipid syndrome, Factor V Leiden, Protein C and S, Prothrombin 20210A were unremarkable.
Biopsy was done which showed thrombotic vasculopathy associated with epidermal necrosis and no
evidence of vasculitis. Given the clinical presentation and histopathology report, heparin induced skin
necrosis was thought to be the most likely diagnosis. UFH was discontinued and replaced by argatroban
drip and lesions gradually resolved.
DISCUSSION: Eventhough, it is uncommon for UFH induced skin necrosis to occur in the absence of
thrombocytopenia or HIT antibodies, the diagnosis should be considered with suspicious skin lesions as
in our case. Classically HIT occurs after 3 to 5 days of initial dosing, however it can happen earlier in
previously sensitized patient (like our case). The presence of such skin lesions should alert the clinician
the risk for systemic thromboembolic events and treatment with alternative thromboprophylactic agent
should be considered
377

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Saeed Ahmed, MBBS
Syncope. First, Let's Make Sure You Don't Die.
Saeed Ahmed, MBBS,Edward Bischof, MD, Jesse Cone MD, Saira Rashid MBBS, Dilan M.R. Jogendra,
MBChBBAO
INTRODUCTION: In a structurally normal heart ventricular tachycardia may be dismissed as a cause of
syncope, however, there are exceptions to this rule. We report a rare, life threatening, cause of
syncope in a structurally normal heart.
CASE PRESENTATION: A 63 year old female with past medical history significant for hypertension and
non cardiac chest pain presented to the emergency department with an episode of syncope. While
getting out of a hot shower the patient lost consciousness, fell, and hit her head. Her husband heard a
thud and rushed into the bathroom finding his wife unconscious. He checked her pulse and noted it to
be irregular. She regained consciousness within a few minutes and had no recollection of the event.
Over the previous several months the patient had multiple episodes of lightheadedness which were
evaluated with holter monitoring, an event recorder, nuclear stress test, and transthoracic
echocardiogram in the outpatient settings and found unrevealing. Her physical exam, lab work, cardiac
enzymes, and 24-hour telemetry monitoring were unremarkable.
DISCUSSION: She was discharged home with follow up with a cardiologist. The cardiologist reviewed
her several EKGs that were read as "INCOMPLETE RBBB", "NON SPECIFIC INTRAVENTRICULAR
CONDUCTION DELAY", and "NON SPECIFIC ST-T ABNORMALITY" in leads V1-V2. He also elicited further
family history of the patient’s mother passing away in her sleep. This raised the possibility of the
Brugada syndrome leading to syncope. The patient underwent an Electrophysiology study which showed
the classic "coved ST pattern" after Ajmaline administration, characteristic of type 1 Brugada syndrome.
She was managed with an Implantable Defibrillator, potentially preventing a life threatening event.
378

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nischala Ammannagari,
MBBS
ACQUIRED HEMOPHILIA IN THE SETTING OF BULLOUS PEMPHIGOID: A RARE PHENOMENON
Nischala Ammannagari MD , Kathleen Laveaux MD, Sara Grethlein MD, Alfred Cretella MD
INTRODUCTION:Acquired Hemophilia is a rare bleeding disorder caused by autoantibodies against
factor VIII. Association with skin diseases like autoimmune bullous diseases is extremely uncommon. We
present one such rare case of acquired factor VIII inhibition in the setting of bullous pemphigoid in an
elderly male.
CASE PRESENTATION: A 69-year old Caucasian male with history of recurrent blistering skin eruptions
of upper extremities (treated with prednisone) presented to our emergency department with worsening
painless and non-pruritic skin blisters and dizziness. At arrival to ER he was found to be hypotensive and
profoundly anemic (Hemoglobin 7.2 and Hematocrit 21.9). This was down dramatically from a prior
hemoglobin of 12.5 two days earlier and 14.7 four days earlier. There was no overt external bleeding, no
trauma, no hemoptysis or hematemesis with negative stool guaic tests.He had ecchymotic patches
between his skin eruptions. Despite receiving multiple units of blood transfusion, his hematocrit failed
to improve. A punch biopsy of skin lesion with immunofluorescence studies revealed bullous
pemphigoid. Coagulation studies revealed an elevated PTT of 49.6 with normal values of PT (10.6),
platelet count (296) and fibrinogen (443). Factor VIII activity was

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Narender Annapureddy
MD
An uncommon Hematological manifestation of Ulcerative Colitis
Narender Annapureddy, MD Vijay Kanakadandi, MD Rishi Malhan, MD Girish Nadkarni, MD MPH CPH
Natraj Ammakkanavar, MD Shiv Kumar Agarwal, MD Manpreet Sabharwal, MD
INTRODUCTION: Ulcerative Colitis (UC) is associated with a number of extraintestinal manifestations in
up to 40% of the cases and can occasionally causes hematological abnormalities. Anemia, autoimmune
hemolytic anemia and rarely Thrombotic Thrombocytopenic Purpura (TTP) can occur. Here we report of
a case of TTP associated with UC.
CASE PRESENTATION: 43 year old female with history of UC was initially admitted for an exacerbation
of UC, treated appropriately and was discharged on mesalamine and prednisone after 2 days of
hospitalization. Patient returned to the hospital 2 days after Discharge with worsening symptoms and
reported that she was noncompliant with her therapy. On the second day of hospitalization her platelets
dropped to 44,000/mm3 from 231,000/mm3 on admission and her hematocrit dropped to 21.6% from
30.5%. she also developed acute kidney injury with a rise in her creatinine from baseline of 0.9 mg/dL to
2.8. Lactate dehydrogenase (8011 u/L), total bilirubin (11.9 mg/dL) and direct bilirubin (1.2 mg/dL) were
elevated. haptoglobulin was decreased at 8 mg/dL, aspartate transaminase(187 U/L) was elevated with
normal alanine transaminase. Complements levels were normal. D-dimer and fibrinogen levels were also
normal. Heparin induced platelets antibodies and Serotonin release assay were both negative.
Peripheral smear showed schistocytes and helmet cells a presumed diagnosis of TTP was made and
patient started on plasmapheresis. Danazol was also started at 600mg per institution policy. Workup for
vasculitis and other autoimmune disorders was negative. ADAMTS-13 activity was 150,000/mm3 and
plasmapheresis was subsequently tapered after a total of 15 days. At the time of discharge her renal
function had returned to baseline and her platelets were 314,000/mm3.
DISCUSSION: Extraintestinal manifestations of UC are reported in up to 40% of patients. Hematological
complications are relatively uncommon except for anemia both from iron deficiency and from chronic
disease. There have been few reported cases of TTP associated with UC and it has been reported to be
relatively resistant to medical management. Both the diseases represent autoimmune disorders and
generally respond well to immunosuppressive therapy. TTP is characterized by fever, microangiopathic
hemolytic anemia, thrombocytopenia, neurological symptoms and renal failure. Idiopathic or acquired
TTP is characterized by inhibition of ADAMTS13, a metalloproteinase responsible for the breakdown
of von Willebrand factor (vWF), which links platelets, blood clots, and the blood vessel wall in the process
of blood coagulation. In any patient with UC with a sudden drop in platelets TTP should be always
considered as early diagnosis and initiation of plasmapheresis can prevent significant mortality and
morbidity.
380

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Narender Annapureddy
MD
Thrombocytopenia in a patient with autoimmune disease
Narender Annapureddy, MD Shiv Kumar Agarwal, MD Manpreet Sabharwal, MD Vijay Kanakadandi, MD
Girish Nadkarni, MD MPH CPH Natraj Ammakkanavar, MD
INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is an uncommon cause of
thrombocytopenia characterized by decreased levels of ADAMTS13. In most of the cases the etiology is
unknown. It has been associated with certain medications, infections like HIV, autoimmune diseases
especially with systemic lupus erthyematosus. Here we report a case of TTP in a patient with
rheumatoid arthritis (RA) on methotrexate.
CASE PRESENTATION: A 22-year-old female with past medical history of RA was brought to the
emergency room for alteration in mental status. Her home medications included methotrexate which
was started 6 months ago when she was diagnosed with RA. Vital signs on presentation were
temperature 101 degrees Fahrenheit, blood pressure 120/78 mm Hg, pulse rate 110/min, respiratory
rate 20/min, oxygen saturation 95% on room air. On physical examination, the patient was lethargic but
had a nonfocal neurological examination. On blood chemistries total bilirubin was 4.8 mg/dL with direct
bilirubin of 1.4 mg/dL, creatinine was 0.9 mg/dL. Aspartate transaminase was elevated at 95 U/L with
normal alanine transaminase. Lactate dehydrogenase was 5768 U/L and haptoglobin was 8 mg/dL. On
blood counts her hematocrit was 18.9% decreased from 35% 6 months ago and her platelets were 13
k/uL decreased from 262 K/uL 6 months prior. Reticulocyte count was 11.7%. D-dimer was evelated at
2.9 ug/mL with normal fibrinogen levels. Peripheral smear showed 2+ schistocytes. A lumbar puncture
was performed given the patient’s mental status, which was negative for cells and for syphilis screen. A
computed tomography angiogram of the chest was performed which was negative for pulmonary
embolism. A presumptive diagnosis of TTP was made and patient was initiated on plasmapheresis along
with prednisone 1mg/kg/day. Antinuclear antibodies were negative, Rheumatoid factor was negative,
Cyclic citrullinated peptide IgG was positive at 128 Units (0-19 Units normal). C3 and C4 levels were
decreased at 67 mg/dL and 7.88 mg/dL. Sjogren antibodies, SSA was positive at 78.50 EU/ML and SSB
was negative. ADAMTS13 levels were decreased at 10% activity. Patient responded after plasmapharesis
for 10 days but recurred within 4 days of tapering plasmapheresis. The patient was then treated with
rituximab intravenously for 4 weeks along with plasmapheresis with good response. Patient had
improvement in mental status and improvement in platelets to 420 K/uL was subsequently discharged
with follow up.
DISCUSSION: Microangiopathic hemolytic anemia (MAHA) presents a diagnostic challenge in patients
with autoimmune disorders as it may be part of the spectrum. Measuring ADAMTS13 levels and other
markers of autoimmune disorders is important as it helps to distinguish between idiopathic TTP
associated with autoimmune disorder versus MAHA from autoimmune disease as it helps guide
therapeutic choices. MAHA from autoimmune disorders might be refractory to plasmapheresis and need
stronger immunosuppresion compared to idiopathic TTP.
381

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nidhi Bansal, MBBS
Mystery trail of unexplained hypercalcemia ends in a food supplement.
Nidhi Bansal, MBBS, Liviu Danescu,MD, Jennifer Kelly MD.
INTRODUCTION: Complementary medicine utilization continues to enjoy an impressive amount of
attention and consumption but their potential for current or future toxicity seems considerable and
concerning. Vitamin D intoxication that is associated with the consumption of dietary supplements is
reported rarely.
CASE PRESENTATION: We present an interesting case of 59 year old caucasian lady with history of
multiple sclerosis, osteoporosis, breast cancer status post lumpectomy , radiation and chemotherapy.
She presented with c/o weakness, fatigue, headache , constipation, short term memory loss and
palpitations. Her metabolic profile showed pre renal azotemia and hypercalcemia (16.2 mg %). She was
started on aggressive intravenous hydration and intensive monitoring leading to rapid resolution of
symptoms. A complete diagnostic work up for hypercalcemia was performed. PTH levels were
suppressed at 5.6 pg/ ml arousing suspicion for hypercalcemia due to malignancy (prior history of breast
cancer/ new primary). However her PTHrP levels were within normal limits (0.8 pmol/ l). TSH (0.623
IU/L) and free T4 (2.87 ng/dl) were also within normal limits. 25- hydroxy Vitamin D level was high at
96ng/ ml, while 1-25 hydroxy vitamin D was 28 pg/ ml (10-65 pg/ ml). Review of her medication list
showed daily intake of 800 units of vitamin D and 500 mg of calcium. With limited sun exposure in
Central New York, how our patient managed to achieve such a degree of symptomatic hypervitaminosis
D became a mystery waiting to be resolved. We investigated her for granulomatous diseases and other
causes of hypervitaminosis D.The patient denied overdosing on prescription vitamin D initially but later
admitted that she was ingesting an expensive naturally derived gel preparation containing about 16,000
IU of vitamin D daily for last 10 months. This was one of several alternative medications she was
prescribed online by practitioner of alternative medicine to cure her multiple sclerosis and osteoporosis.
We counseled and provided information to the patient on potential side effects of excessive vitamin D
supplementation and other alternative preparations and withheld the same at the time of discharge.
DISCUSSION: Annually, 34 billion dollars are spent on complementary and alternative medicine (CAM)
in the U.S.A. . Surveys suggest that the potential for a negative drug - supplement interaction
in users can be as high as 40%.The majority of the expense on CAM is directed towards “self-care,” and
is done without physician approval or guidance. CAM is not regulated by the FDA , thus
manufacturers tend to make unfounded health benefit claims while concealing the potential side effects
as was the case with our patient.
382

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Ruthie May U Chua, MD
Adrenal Carcinoma Presenting as Hypoglycemia: A Case Report
Ruthie May U Chua, MD Joanna Manzano MD, Moshe Schiffmiller MD, Jennifer Poste, Stephen
Jesmajian
INTRODUCTION: Cushing’s syndrome can be secondary to a rare primary adrenocortical malignancy.
Patients with functional adrenocortical tumor present a unique challenge because of complexities in
diagnosing and managing multiple metabolic derangements.
CASE PRESENTATION: We present the case of a 55 year-old overweight African American gentleman
with history of insulin-dependent diabetes mellitus, hypertension, vitamin D deficiency and
schizophrenia who was admitted for seizure secondary to a hypoglycemic episode. The patient had
multiple Emergency Room visits for both hypoglycemia and hyperglycemia over the past two months.
During the current hospitalization his blood glucose on admission was 23 mg/dl. His insulin was held and
he was started on intravenous dextrose. Laboratory exam revealed metabolic alkalosis with a
bicarbonate of 36.5 mmol/L and hypokalemia with potassium of 2.5 mmol/L. He remained hypokalemic
despite repletion. Multiple hypoglycemic episodes ensued despite holding insulin.
On review of previous radiographic records done two months prior to admission, patient was found to
have an 8x9x11 cm heterogeneous lobulated soft-tissue mass contiguous with the left kidney, pancreas
and stomach. A second CT performed approximately one month later showed new pulmonary and
hepatic masses suspicious for metastases. Review of previous laboratory records revealed low
aldosterone:renin ratio (1ng/dl:3.94ng/ml), C peptide (0.22ng/ml) and insulin (less than 2 micro IU). We
performed a 1 mg dexamethasone suppression test which confirmed hypercortisolism with serum
cortisol level of 31.2 mcg/dL. A Serum ACTH while the patient was hypoglycemic was within normal
limits (34pg/ml). The diagnosis of advanced adrenocortical carcinoma (ACC) with Cushing’s syndrome
was suspected and chemotherapy with mitotane was planned. The patient however had persistent
hypoglycemic episodes and subsequently went into cardiopulmonary arrest.
DISCUSSION: Adrenocortical carcinoma is highly aggressive and rare, occurring in approximately 1 per
million population per year. Sixty percent of these tumors are secretory, of which 45% cause Cushing’s
syndrome. Clinical symptoms develop very rapidly in a course of few months. This patient presented
with symptoms of Cushing’s syndrome confounded with repeated hypoglycemic episodes. This
increased glucose utilization is thought to be most likely induced by paracrine release of insulin-like
growth factor 2. CT scan findings are typical of adrenal cancer and biopsy is not necessary to establish a
diagnosis of a primary malignancy. Primary curative treatment for ACC is surgery. Our patient who
already presented with advanced disease was not a candidate for surgery and would have benefited
from mitotane therapy. However, five year survival rate of advanced disease is still only 10%. This case
illustrates that repeated hypoglycemia in a diabetic patient warrants more than cursory quick fixes and
should prompt physicians to investigate further.
383

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Karen de Castro Dah, MD
THORACIC ENDOMETRIOSIS IN A YOUNG WOMAN PRESENTING WITH ABDOMINAL PAIN
Karen de Castro Dah, MD Second Author: Nelson Chan-Hung, MD
INTRODUCTION: Endometriosis is a disease characterized by the presence of endometrium-like
tissue outside of the uterine cavity. The disease affects 5-15% of women in the reproductive age, where
up to 12% are extrapelvic in location. An estimated 2% of extrapelvic endometriosis involves the
thorax.
CASE PRESENTATION: A twenty seven year old Haitian female presented to the emergency
department with abdominal pain associated with the onset of her menstruation. She denied any chest
pain or shortness of breath. Routine chest x-ray showed a large right pleural effusion and 2000
milliliters of bloody pleural fluid was drained in the emergency department. Abdominal computed
tomography scan showed bilateral cystic appearing adnexa and a large right pleural
effusion. Transvaginal ultrasound showed a normal sized uterus with thickened endometrium and
bilaterally thickly enlarged ovaries with small cystic structures. She underwent a diagnostic laparoscopy
and both peritoneal and vaginal biopsies were taken. Clinical diagnosis indicated Stage IV endometriosis
however the biopsies revealed no evidence for endometriosis. Thoracic surgery performed video
assisted thoracic surgery with right upper and middle lobe wedge resection and additional biopsies of
the right diaphragm and parietal pleura were taken. The samples were consistent with
endometriosis. The patient had no major complications from the procedure and received hormonal
treatment with leuprolide and medroxyprogesterone before discharged.
DISCUSSION: This case represents a rare disease entity that has yet to be fully discovered. Thoracic
endometriosis, the growth of endometrial tissues in the lungs or on the pleura, comprises four clinical
findings including catamenial pneumothorax, hemothorax, and hemoptysis, and endometriotic lung
nodules. Catamenial hemothorax occurs in approximately 14% of thoracic endometriosis and involves
the right side in almost all reported cases. Presently, there is a lack of a single proposed hypothesis
explaining the mechanism of intrathoracic endometrial implantation, and general information pertaining
to thoracic endometriosis remains in short supply. Current treatment of thoracic endometriosis consists
of both hormonal treatment, with oral contraceptives or gonadotropin-releasing hormone agonist, and
surgical removal of involved areas through video assisted thoracic surgery or open thoracotomy which
provides targeted treatment to the affected areas. With no treatment modality having yet been shown
to be both superior and effective, data regarding short and long term treatment outcomes remains both
variable and scarce.
384

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Amishi Desai, MBBS
Ayurvedic Remedy For Diabetes As A cause Of Lead Poisoning
Amishi Desai, MBBS Harry Staszewski MD
INTRODUCTION: The popularity of alternative or complementary medicine has dramatically increased
over the years. They are assumed by patients to be safe and free of side effects. Ayurveda, a traditional
medical system in India, has been in practice for more than 5000 years. Published case reports have
demonstrated that ayurvedic formulations may contain large quantities of heavy metals and it is
possible that these minerals are added intentionally after the formulations have undergone a
“detoxification” process.
CASE PRESENTATION: We present a 56 year old male, who came to the emergency room with diffuse
abdominal pain, decreased oral intake and constipation. Laboratory values showed that hemoglobin had
dropped to 9.7 grams per deciliter (from a baseline of 14 grams per deciliter). Levels of serum iron,
transferrin, haptoglobin, vitamin B12 and folic acid were within normal limits. Patient had a normocytic
anemia with elevated reticulocyte count and liver enzymes were mildly elevated. Abdominal computed
tomography was normal. He underwent an upper endoscopy and a colonoscopy which were negative.
Peripheral smear showed prominent basophilic stippling promoting measurement of blood lead levels
that was markedly elevated (101 microgram per deciliter). Emergent chelation therapy with dimercaprol
(BAL) and calcium EDTA was started and patient was later discharged on oral succimer for two weeks.
On further enquiry patient reported travel to India three months back where he was prescribed
ayurvedic medicine for diabetes which he had been taking continuously since 2-3 months. The ayurvedic
powder was sent for chemical analysis. The lead content was 62 percent.
DISCUSSION: According to Ayurveda, toxic heavy metals such as lead and mercury play an important
role in healthy functioning of the human body. Ayurvedic medications have been used in the past for
pain, arthritis, psoriasis, impotence, infertility and as aphrodisiacs. Lead toxicity from ayurvedic
medicine, used for diabetes has rarely been reported. To our knowledge there have been only three
documented case reports where lead toxicity has occurred from an ethnic remedy taken for diabetes
and its long term complications. People opt for alternative medicine because they believe it has lesser
side effects than a more natural form of therapy. In ayurvedic medicine lead is regarded as an
aphrodisiac and its role may have been to counter the impotence associated with diabetes. The present
case brings to light the need to take a thorough medical history, including previous and current drug
therapy. However, some patients do not consider herbal medications drugs, whereas, others are
uncomfortable about providing information on the use of these preparations. Thus physicians must
specifically ask patients about their use of unconventional medicines.
385

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Christopher Dittus, DO
A RARE FINDING IN A RARE OVARIAN MALIGNANCY
Christopher Dittus, DO (Associate Member) Second Author: Christos Fountzilas, MD (Associate
Member) Third Author: Robert Graham, MD (Fellow) Fourth Author: Amanda Magee, DO (Member)
INTRODUCTION:Ovarian malignancies have the highest mortality of all female gynecologic tumors in
the United States. According to the WHO Classification of ovarian neoplasms, 65% of these tumors are
epithelial in origin, 25% are of germ cell origin, and 6% are of sex-cord stromal origin. Less than 1% of all
ovarian malignancies are carcinosarcomas. A unique and rare entity is carcinosarcoma with
neuroendocrine differentiation. These tumors have been documented in other organs, but to our
knowledge there are no reported cases of primary ovarian origin. Herein, we present a case of
carcinosarcoma of the ovary with neuroendocrine differentiation.
CASE PRESENTATION: A 60-year-old female presented with right lower extremity edema extending to
the upper thigh. The patient’s medical history included chronic hepatitis C and a remote history of
breast cancer. Physical examination revealed distended abdomen with a large, palpable mass and right
lower extremity pitting edema and tenderness. Computerized tomography of chest, abdomen and pelvis
revealed extensive bilateral pulmonary emboli, including saddle embolism, right common femoral deep
venous thrombosis, and a large heterogeneously enhancing mass projecting from the pelvis into the mid
abdomen. The patient was subsequently referred to surgery for elective total abdominal hysterectomy
with bilateral salpingo-oophorectomy and omentectomy. Histology revealed carcinosarcoma consisting
of a high-grade neuroendocrine epithelial component and a rhabdomyosarcomatous mesenchymal
component. The tumor was most consistent with an ovarian primary. The patient declined further
treatment and was discharged to hospice.
DISCUSSION: While carcinosarcomas of the ovary have been well documented, carcinosarcomas of the
ovary with neuroendocrine differentiation have not been well described. Carcinosarcomas contain both
malignant epithelial and sarcomatous elements. The epithelial component is most often
adenocarcinoma, but may also be squamous cell carcinoma. Very rarely the epithelial component
consists of neuroendocrine tissue, which has been described more commonly in gastric, esophageal,
uterine, and adnexal lesions. The sarcomatous element may be homologous tissue native to the ovary,
or heterologous tissue not native to the ovary. Patients present with symptoms similar to those with
epithelial ovarian cancer, but have comparatively worse outcomes. After cytoreductive surgery, the
consensus recommendation for carcinosarcoma of the ovary is a platinum-based chemotherapy
combination. This chemotherapy regimen generally has a poor response rate due to the inherent
heterogeneity of the tumor. Our patient’s case was complicated due to the tumor’s neuroendocrine
differentiation. Consequently, carcinosarcomas with neuroendocrine differentiation must be researched
further, as they are extremely rare tumors that are associated with poor outcomes.
386

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Shira B Eytan, MD
A Rare Case of Campylobacter jejuni Associated Myocarditis
Shira B Eytan, MD Robert E Graham MD, MPH
INTRODUCTION:Campylobacter jejuni is a common cause of food poisoning, enteritis and diarrhea
worldwide. Although rare, we present a potentially life threatening complication: Campylobacter jejuni
associated myocarditis in an immunocompetent patient.
CASE PRESENTATION: A 34 year old previously healthy white man presents with a three-day history of
watery diarrhea, fever, cough productive of clear phlegm, abdominal and chest discomfort,
chills, general malaise, no fevers. He also reported multiple episodes of watery diarrhea. Patient is from
Australia and vacationing on his honeymoon in the US; he had just arrived in New York from the west
coast when he presented to our emergency department. Past medical history includes depression for
which he takes Paroxetine, but he denies any pulmonary, cardiac, or gastrointestinal history.
Levofloxacin was initiated for presumed pneumonia in light of cough and possible effusion/consolidation
on chest x-ray. Leukocytosis of 22 x103/uL was found and blood cultures were negative. Cardiac profile
returned slightly positive with Troponin I 0.145ng/ml, CK 134 U/L. EKG at this time showed normal sinus
rhythm with LBBB, with no old EKG for comparison. Echocardiogram was performed which showed
severely hypokinetic walls, and an estimated left ventricular ejection fraction of 20-25%. At this point,
patient was diagnosed with myocarditis and transferred to CCU for closer monitoring. Subsequent CT
angiogram for cardiac structure showed normal coronary arteries. Infectious and rheumatologic workup
for the cause of myocarditis returned only a positive Campylobacter jejuni stool culture. Patient was
continued on Levofloxacin, and diarrhea resolved. He was discharged six days after admission with an EF
of 54%.
DISCUSSION: Myocarditis is a rare but potentially serious complication of infectious disease, with
potential sequelae of life-threatening arrhythmia and congestive heart failure. There have only been a
few reported cases of Campylobacter jejuni associated myocarditis. Interestingly, the majority of cases
have occurred in young immunocompetent males, and resulted in completed resolution. Although the
pathophysiology is unclear, it is thought to be caused by an autoimmune inflammatory reaction. This
case highlights the need for consideration of Campylobacter jejuni infection as a cause of new
myocarditis in an immunocompetent patient with enteritis.
387

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Christos Fountzilas, MD
Dabigatran overdose secondary to acute kidney injury
Christos Fountzilas, MD, Christopher Dittus DO, Jerry George DO, Randy Levine MD.
INTRODUCTION:Direct thrombin inhibitors and factor Xa inhibitors have improved treatment of non
valvular atrial fibrillation, with more predictable pharmacokinetics and pharmacodynamics when
compared to warfarin. However, safety concerns have been raised since there is no antidote to these
new agents for treatment of secondary hemorrhages.
CASE PRESENTATION: We present the case of an 82 year old female with a history of non valvular
atrial fibrillation who was switched from warfarin to dabigatran one week prior to presentation, and
who presented with evidence of dabigatran overdose.
The patient presented to the emergency department with complaints of generalized weakness, dizziness
and decreased appetite for the past 2 days along with nausea and an episode of vomiting the day of
presentation. The patient denied melena, hematochezia, hematemesis, hemoptysis, epistaxis, or any
other signs of bleeding. Apart from atrial fibrillation, the patient had a history of chronic systolic
congestive heart failure with implantation of an AICD, coronary artery disease, hypertension and
hyperlipidemia. She had been treated with dabigatran 150 mg twice daily, carvedilol, simvastatin,
furosemide and amiodarone.
Vital signs on admission were stable and physical examination unremarkable. A complete blood count
was significant only for mild thrombocytopenia (platelets 95,000/mcl) which had been stable for several
years. The peripheral blood smear showed occasional schistocytes. Chemistry revealed only elevated
creatinine of 1.78 mg/dl from a baseline of 1 mg/dl one week before. INR was 7.25 and PTT 135 seconds.
The patient denied any warfarin, and that was confirmed with the patient’s home health assistant and
family.
Fibrinogen level was below 80mg/dl, D-Dimer level less than 150 ng/dL and thrombin time was more
than 120 seconds, consistent with excessive anticoagulation secondary to dabigatran. Dabigatran was
held with resolution of coagulopathy over the next 4 days. Subsequently, dabigatran was started at a
lower dose of 75mg twice daily.
DISCUSSION: We present the case of dabigatran overdose in a patient who was treated with a
seemingly appropriate dose. Our patient developed mild renal insufficiency after a brief gastrointestinal
illness (possibly due to dehydration) which led to decreased clearance of the drug. This was
compounded by the concomitant intake of amiodarone, a p-glycoprotein inhibitor that can increase
peak plasma concentrations of dabigatran. The combination of these two events led to her overdose
and presents a cautionary tale.
388

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sharon George MD
The Story Of A Tricky Tick
Sharon George MD, Sowmya Korapati MD, Shaifali Sandal MD, Hernan Rincon-Choles MD
INTRODUCTION: Diabetic ketoacidosis (DKA) is a potentially lethal condition often presenting in
patients who have an underlying disease process or are poor compliance with their insulin regimen.
Ehrlichiosis while endemic in the Southeastern, South Central, and Mid-Atlantic regions of the United
States is rare in Central New York especially in the winter months.
CASE PRESENTATION: We present the case of an 80 year old veteran who presented with 3 week
history of worsening malaise, fevers, night sweats, along with nausea and abdominal pain that was also
associated with poor oral intake. The patient was subsequently found to be in DKA with an elevated
anion gap and was transferred to the ICU. At the time of admission, he was also found to have
thrombocytopenia, mild anemia, leukopenia and elevated liver enzymes. Since he was noted to be
febrile, blood cultures and urine culture were also ordered to identify a possible infectious
etiology. While a staff member was helping the patient in the ICU, she noticed an engorged tick on the
patient’s left shoulder. The tick was procured for arthropod identification and was found to be Ixodes
sp. Patient was treated with Doxycycline as well as Azithromycin and Atovaquone to treat for possible
co-infection with other tick borne illnesses. On further inquiring, patient admitted to visiting his
daughter in Mount Kisco in Westchester County, NY for Thanksgiving and going for a long walk in the
woods three weeks prior to his admission. Subsequently, thin and thick smears, and serologies were
sent for identification of possible tick borne illnesses including Lyme’s disease, Babesiosis, Rocky
Mountain Spotted Fever, Anaplasmosis, and Ehrlichiosis. Patient’s blood smear demonstrated
intracytoplasmic inclusions (morulae) suggestive of Granulocytic Ehrlichiosis.
DISCUSSION: Human ehrlichiosis is a serious disease with significant morbidity, particularly if
appropriate antibiotics are delayed. Through this case we hope to highlight that one should have a high
degree of suspicion for tick borne infections in endemic areas regardless of the season. The timely
discovery of a tick on our patient was potentially life-saving. A physical exam in a febrile patient should
include a thorough skin exam for tick bites. We also would like to emphasize that until a confirmed
diagnosis is obtained, patients should be empirically treated for all tick-borne diseases as the often
typical clinical findings of rashes of Rocky Mountain Spotted Fever or Lyme’s disease may mislead the
clinician into ignoring possible co-infection with ehrlichiae or babesia.
389

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Robert J Gianotti III
When the Bleeding Won’t Stop: A Case Cluster of Ruptured Hepatoma
Robert J Gianotti III, Keri Herzog, Karin Warltier
INTRODUCTION: Hepatocellular carcinoma is one of the most common tumors worldwide, with up to
85% of cases occurring with cirrhosis. Tumor rupture is a rare, but morbid complication occurring in 3-
15% of cases, with a higher incidence in Asia. A high index of suspicion for rupture is needed for prompt
recognition in patients with the acute onset of abdominal pain in the setting of hepatocellular
carcinoma.
CASE PRESENTATION: Case 1: A 22 year old man from Guinea with no medical history presented to
our hospital complaining of abdominal distention and anorexia. On physical exam he was noted to have
a large, firm abdominal mass. Computed tomography of the abdomen revealed a giant hepatoma of the
right and middle lobes of the liver with compression of the supra-renal inferior vena cava. He was
diagnosed with chronic Hepatitis B infection. Prior to beginning treatment with Sorafenib, he had an
acute onset of abdominal pain and tachycardia. Repeat imaging revealed rapid tumor progression and
hemorrhage anterior to the falciform ligament with active contrast extravasation. The patient was
admitted to our palliative care unit and subsequently passed away.
Case 2: A 65 year old man with hepatitis C initially presented to an outside hospital complaining of
nausea and vomiting. On exam he had ascites and paracentesis showed frank blood. Computed
tomography showed cirrhosis, multiple liver masses and a large hematoma posterior to the right lobe of
the liver. He required multiple blood transfusions and was transferred to our hospital for possible transarterial
embolization. On transfer the patient was tachypneic with severe abdominal pain. The patient's
prognosis and options were discussed. He wished to focus on achieving comfort. The patient was
transferred to our palliative care unit.
Case 3: A 74 year old man with a history of alcoholism and hepatitis C presented to our hospital with
abdominal pain. He had a tender and distended abdomen. Computed tomography showed a 15 cm
heterogeneous tumor abutting the right hepatic vein and IVC within a nodular liver. Alpha-fetoprotein
was 179 ng/mL. He was not considered a surgical candidate due to the large size of the tumor. On
hospital day 7, he reported severe abdominal pain and had worsening anemia. Diagnostic paracentesis
revealed frank blood, confirming hemoperitoneum. He was planned for trans-arterial embolization, yet
passed away before any intervention.
DISCUSSION: Here we report a universally fatal outcome in patients presenting with rupture in the late
stages of hepatocellular carcinoma. Diagnostic paracentesis and computed tomography can confirm
both the presence of and source of blood. Early referral to hospice was the treatment of choice in our
cohort, and should be considered only in patients with very advanced disease and poor prognosis.
Patients with good functional status, adequate liver function or smaller tumor size who present with
tumor rupture should be urgently referred for trans-arterial embolization and in some cases,
hepatectomy.
390

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Arun Gopal, MD
Massive Right Atrial Thrombosis: A Sequela of Hepatocellular Carcinoma
Arun Gopal, MD Second Author: Nirvani Goolsarran, MD Third Author: Marisa Siebel, MD Division of
Hematology-Oncology Department of Medicine Stony Brook School of Medicine Stony Brook, NY 11794
INTRODUCTION: Hepatocellular carcinoma has been known in rare instances to metastasize to the
right atrium. We report a case of a newly diagnosed Grade 2-3 Hepatocellular carcinoma that initially
presented with vague complaints of abdominal pain, constipation and shortness of breath. The unusual
clinical presentation was consistent with tumor thrombosis of the inferior vena cava (IVC) extending to
the right atrium and encroaching the tricuspid valve. This case demonstrates a life-threatening
manifestation of metastatic hepatocellular carcinoma and highlights the importance of early diagnosis in
these patients.
CASE PRESENTATION: A 61 year old morbidly obese female presented to the emergency department
with 4 day complaints of diffuse abdominal pain described as dull, constipation and mild shortness of
breath on exertion. Past medical history was significant for COPD, hepatitis C (treated) and SLE. On initial
presentation her vitals were as follows: BP 141/88, P 104, R 18, T 36.7. Physical exam was remarkable
only for tachycardia and mild RUQ tenderness. Abdominal CT scan revealed the presence of a large
filling defect in the inferior vena cava with extension into the right atrium, as well as a liver lesion. Twodimensional
echocardiogram demonstrated a large mobile echodensity in the right atrium, measuring
approximately 5.33 x 2.81 cm and intermittently descending into the plane of the tricuspid valve. The
diagnosis of HCC was presumed based on an alpha-fetoprotein titer of 144,912 and CT imaging that
supported this diagnosis. This was later confirmed on liver biopsy. The patient was evaluated by
cardiothoracic surgery, however due to her poor functional status she was deemed unfit for surgery.
Medical oncology was consulted, and the patient was informed that she may be a candidate for
Nexavar. The patient was stabilized and ultimately discharged home, but was readmitted soon
thereafter in fulminant hepatic failure and passed away in the hospital less than 3 weeks after her initial
diagnosis.
DISCUSSION: Cardiac involvement in HCC is rarely encountered. It usually indicates a more advanced
form of disease with poor prognosis. Presenting symptoms often mimic those of heart failure but may
be nonspecific as in the case of our patient. There are reports of patients with good functional status
who underwent surgical removal of right atrial mass with good outcomes. Our patient was unfit for
surgery and based on her Childs-Pugh score, she was not eligible for Nexavar (Sorafenib). Patients in this
situation are often left with only the option of palliative therapy. The detection of extrahepatic
metastatic disease, therefore, becomes crucial in the early diagnosis and treatment of HCC.
391

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Vanya Grover, DO
Cytomegalovirus Induced Collapsing Focal Segmental Glomerulosclerosis
Vanya Grover, DO Additional Authors: Meghana Gaiki, MD, Maria Devita, MD and Joshua Schwimmer,
MD
INTRODUCTION: Collapsing glomerulopathy is a rare cause of rapidly progressive renal failure. It is
considered a variant of focal segmental glomerulosclerosis, occurring in both immunocompetent and
well as immunocompromised hosts. Etiologies include viral infections, lymphoproliferative disorderes,
and autoimmune disease. We present a rare case report linking cytomegalovirus infection to collapsing
glomerulopathy in an immunocompetent host.
CASE PRESENTATION: A 34 year old Hispanic male with no significant past medical history presented
with the complaint of generalized malaise, nausea, and vomiting ten days prior to admission. He
reported a monogamous relationship with his wife for the past eight years and denied any alcohol,
intravenous drug or tobacco use. Physical exam was significant for blood pressure of 139/92 as well as
1+ pitting edema in bilateral lower extremities. Laboratory data demonstrated a serum creatinine of
7.37 mg/dL, urea of 72mg/dL. Urine microscopy was unremarkable and urinalysis showed protein (3+),
blood (3+), with

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jehad M Haggiagi, MD
Remitting Seronegative Symmetric Synovitis with Pitting Edema Associated with Acute Cholecystitis: A
Case Report.
Jehad M Haggiagi, MD Second Author: Karen Beekman, MD Third Author: Jennifer Wang, MD Fourth
Author: Aman Deep, MD
INTRODUCTION:Remitting Seronegative Symmetric Synovitis with Pitting Edema (RS3PE) is an unusual
inflammatory arthritis with an unknown pathophysiology characterized by an acute onset of
symmetrical synovitis with pitting edema of the hands and/or feet. We report a case of RS3PE and acute
cholecystitis presenting at approximately the same time.
CASE PRESENTATION: A 42-year-old woman presented to the emergency department with severe,
non-radiating right upper quadrant pain for two days. The patient described a dull sensation initially
associated with nausea, non-bloody, non-bilious vomiting. The next day, the patient suddenly developed
pain and swelling of both hands. No preceding history of trauma, headache, fever, drug intake, diarrhea,
or other joint involvement was reported. Her past medical history was unremarkable. Physical exam
revealed right upper quadrant tenderness and positive Murphy’s sign. Examination of both hands
revealed bilateral swelling, pitting edema of the dorsum and tenderness in all the joints. Labs revealed a
white blood cell count of 14 per microliter, erythrocyte sedimentation rate (ESR) of 82 mm/hr, and a Creactive
protein (CRP) of 43 mg/l. Right upper quadrant sonogram showed findings consistent with
acute cholecystitis. MRI of both hands revealed bilateral synovitis of the wrists, metacarpophalangeal,
proximal and distal interphalangeal joints and diffuse subcutaneous edema. Rheumatoid factor (RF),
anti-cyclic citrullinated protein (anti-CCP), antinuclear antibodies (ANA), anti-dsDNA, anti-Ro, anti-La,
Human Leukocyte Antigen B27, and Hepatitis B and C were all negative. The diagnosis of RS3PE was
suggested. A laparoscopic cholecystectomy was performed. On post-operative day one, the swelling and
tenderness improved dramatically. One week after discharge, the edema and tenosynovitis resolved
completely.
DISCUSSION: RS3PE Syndrome is a rare inflammatory disease, first described by McCarty et al. in 1985.
RS3PE Syndrome is now regarded as a distinct clinical entity. It has a 4:1 male:female predominance.
Mean age at presentation in one study was 71 years with a range of 48-86. The etiology is still unknown.
Possible factors associated with RS3PE include malignancy, Human Leukocyte Antigen, Parvovirus B19,
and medications. Many reports suggest that RS3PE is a paraneoplastic syndrome. The pathologic
mechanism of RS3PE is still unclear. Vascular endothelial growth factor (VEGF) plays a major role in
pathological changes. ESR and CRP may be markers used to monitor activity, but RF and ANA are always
negative. RS3PE is also characterized by a prompt response to glucocorticoids. Hydrochloroquine can be
used with a lower dose of steroids. However, poor prognosis has been noted among patients with RS3PE
and malignancy. In conclusion, to date, there have been no reported occurrences of RS3PE syndrome
associated with acute cholecystitis, and our patient was successfully treated with only a laparoscopic
cholecystectomy; this observation may be helpful in understanding the pathogenic mechanism of
RS3PE, revealing a more inflammatory basis for the disease not necessarily rheumatologically rooted.
393

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Stephan Heo
A Case Of Cholangitis – It Was A Fluke
Stephan Heo second and third authors: Rebecca Summers, M.D., Nicole Adler, M.D.
INTRODUCTION: A 45 year-old Chinese man presented with worsening abdominal pain, nausea, and
vomiting over a three month period. His history began when he was born and raised in Caton, China,
immigrating to the United States in adulthood. He was in his usual state of good health until three
months prior to admission, when he noted the onset of abdominal pain. This progressed to worsening
burning, sharp epigastric pain with radiation to the right side of the lower ribs.
Physical exam revealed icteric sclera and tenderness to palpation in the epigastric and right upper
quandrant area. His skin was jaundiced. Laboratory results were remarkable for an aspartate
aminotransferase of 496 IU per liter, alanine aminotransferase 824 IU per liter, total bilirubin 8.5 mg per
deciliter, and conjugated bilirubin 2.7 mg per deciliter. His white blood cell count was 13, 200 with 2%
eosinophils.
An ultrasound demonstrated intrahepatic dilatation and a mildly dilated common bile duct measuring 7
cm. An endoscopic retrograde cholangiopancreatography revealed a black, pigmented stone near the
ampulla with innumerable liver flukes. The liver flukes were unable to be obtained during the
procedure, however, stool analysis revealed the presence of ova from Clonorchis Sinensis. Praziquantal
25mg/kg every six hours for a total of three doses were given. His condition improved, and repeat stool
testing showed resolution of the infection.
Acute illness from Clonorchis Sinensis can occur after consumption of ova. General malaise, abdominal
discomfort, and diarrhea begin ten to sixteen days after consumption and can last two to four
weeks. The severity of symptoms is based on the number of flukes involved. Mild infections occur when
less than 100 flukes are ingested, and present with malaise, intermittent jaundice, diarrhea and
abdominal pain. Moderate infections occur with ingestion of 1000 flukes and symptoms include fevers,
chills, anorexia, and weight loss. Ingestion of greater than 1000 flukes causes symptoms of acute right
upper quadrant pain and jaundice. Recognition and treatment with praziquental or an alternative agent
such as albendazole is critical to prevent hepatic destruction, portal hypertension, and cirrhosis[1].
Over 35 million people in Asia are infected with Clonorchis Sinensis. In endemic areas such as
Guangdong, China, over 78.5%-85% of the individuals are infected. Factors that contribute to the
disease include lavatories that are built adjacent to fish ponds, domestic animal feces supplemented to
the ponds to feed the fish, raw fish consumption, and the lack of education about the disease [2]. Of
1521 people interviewed in Guangdong, 64% did not know about fluke disease, and those who did
thought it was only a mild illness [3 ].
Obtaining a thorough history and appropriate diagnostic testing in patients at risk for the disease is
paramount to early recognition and treatment.
CASE PRESENTATION: A 45 year-old Chinese man presented with worsening abdominal pain, nausea,
and vomiting over a three month period. His history began when he was born and raised in Caton,
China, immigrating to the United States in adulthood. He was in his usual state of good health until
394

three months prior to admission, when he noted the onset of abdominal pain. This progressed to
worsening burning, sharp epigastric pain with radiation to the right side of the lower ribs.
Physical exam revealed icteric sclera and tenderness to palpation in the epigastric and right upper
quandrant area. His skin was jaundiced.
Laboratory results were remarkable for an aspartate aminotransferase of 496 IU per liter, alanine
aminotransferase 824 IU per liter, total bilirubin 8.5 mg per deciliter, and conjugated bilirubin 2.7 mg
per deciliter. His white blood cell count was 13, 200 with 2% eosinophils.
An ultrasound demonstrated intrahepatic dilatation and a mildly dilated common bile duct measuring 7
cm. An endoscopic retrograde cholangiopancreatography revealed a black, pigmented stone near the
ampulla with innumerable liver flukes. The liver flukes were unable to be obtained during the
procedure, however, stool analysis revealed the presence of ova from Clonorchis Sinensis. Praziquantal
25mg/kg every six hours for a total of three doses were given. His condition improved, and repeat stool
testing showed resolution of the infection.
DISCUSSION: Acute illness from Clonorchis Sinensis can occur after consumption of ova. General
malaise, abdominal discomfort, and diarrhea begin ten to sixteen days after consumption and can last
two to four weeks. The severity of symptoms is based on the number of flukes involved. Mild infections
occur when less than 100 flukes are ingested, and present with malaise, intermittent jaundice, diarrhea
and abdominal pain. Moderate infections occur with ingestion of 1000 flukes and symptoms include
fevers, chills, anorexia, and weight loss. Ingestion of greater than 1000 flukes causes symptoms of acute
right upper quadrant pain and jaundice. Recognition and treatment with praziquental or an alternative
agent such as albendazole is critical to prevent hepatic destruction, portal hypertension, and
cirrhosis[1].
Over 35 million people in Asia are infected with Clonorchis Sinensis. In endemic areas such as
Guangdong, China, over 78.5%-85% of the individuals are infected. Factors that contribute to the
disease include lavatories that are built adjacent to fish ponds, domestic animal feces supplemented to
the ponds to feed the fish, raw fish consumption, and the lack of education about the disease [2]. Of
1521 people interviewed in Guangdong, 64% did not know about fluke disease, and those who did
thought it was only a mild illness [3 ].
Obtaining a thorough history and appropriate diagnostic testing in patients at risk for the disease is
paramount to early recognition and treatment.
395

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Elena Katz, MD
Extensive Cardiac Tumor Arising from Renal Cell Carcinoma
Elena Katz, MD Nataliya Mar, MD Solaiman Futuri, MD Dana Shani, MD
INTRODUCTION: Secondary cardiac neoplasms occur 20-40 times more frequently than native tumors,
most often originating from hematologic malignancies, or primary skin, lung and breast cancers.
Metastases from renal cell carcinoma (RCC) are exceedingly rare. We report a case of an extensive
cardiac tumor arising from RCC.
CASE PRESENTATION: A 73-year old Hispanic male, who has not seen a physician in over 20 years,
presented as an outpatient with new–onset of leg edema and dyspnea. Past medical, surgical and social
histories were unremarkable. Review of systems was negative for any weight change, flank pain or
hematuria. On physical exam the patient had decreased breath sounds at the lung bases and bilateral 2+
pitting pedal edema. The relevant abnormal laboratory studies included a BUN of 53 ml/dL, creatinine of
1.83 mg/dL, AST of 58 U/L, ALT of 159 U/L, total bilirubin of 1.4 mg/dL, and platelets of 89 x10 3 uL.
Urinalysis revealed 1+ proteinuria. An echocardiogram showed a mass within the right atrium. A cardiac
computed tomography (CT) scan revealed a 5.0 by 4.0 cm right atrial mass with a 2.5 cm by 1.0 cm
projection into the right ventricle. Subsequent CT angiography identified another 4.9 cm by 4.3 cm mass
in the left kidney, with tumor thrombus extending through the circumaortic left renal vein into the
inferior vena cava (IVC), right renal vein and the heart. Radiologic appearance was consistent with RCC.
Liver cirrhosis and moderate ascites were also present. A radionuclide renal scan showed diminished
renal function bilaterally, left (26%) worse than right (74%). The patient refused a tissue biopsy as well
as any therapeutic intervention.
DISCUSSION: RCC constitutes 3% of all adult malignancies and 90-95% of neoplasms arising from the
kidney. Twenty-five to thirty percent of patients are asymptomatic at the time of diagnosis, with disease
found incidentally on radiologic studies. A third of patients presents with metastases, involving the
lungs, liver, bones, lymph nodes as well as the brain. Cardiac involvement is very rare. Only 5-10% of
RCCs develop a tumor that propagates into the renal vein or IVC with further extension into the right
atrium in 1% of patients. This can clinically manifest with symptoms of decompensated heart failure as
was seen in our patient. Thus, cardiac metastasis must not be overlooked in the differential for the
cause of ventricular outlet obstruction in those presenting with symptoms of acute heart failure of
unclear etiology. Of note, the diagnosis in this case rested on multidetector CT images, which having
97% specificity for predicting tumor presence in the renal vein and IVC are an accepted diagnostic
modality.
396

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jehanzeb Khan, MBBS
Catastrophic Antiphospholipid Antibody Syndrome with Reversible Dilated Cardiomyopathy: A Rare
Association and Challenges in Treatment
Jehanzeb Khan, MBBS Lisa Seo, Mohini Bollineni, Cheriyan Thomas, Ritesh Kumar, Karen Beekman
INTRODUCTION: Catastrophic antiphospholipid antibody syndrome (CAPS) is a distinctly rare dramatic
condition characterized by widespread thrombosis of small vessels, first described in 1992 by Ronald
Asherson. Antiphospholipid antibody syndrome (APS) is associated with recurrent arterial and venous
thrombosis. Infections, trauma, medication, or surgery can be identified in about half the cases as a
trigger for CAPS. It is thought that cytokines are activated leading to a ‘cytokine storm’ with the
potentially fatal consequence of organ failure. The mortality is extremely high (50%)when the disease
accelerates to a catastrophic course. Less than 0.8% of all patients with APS present with a catastrophic
form. CAPS by definition develops within a week and is characterized by multiorgan damage (three or
more) and persistence of antiphospholipid antibody. This disorder has a predilection for the lung, brain,
heart, and kidney. CAPS has also been rarely associated with thrombosis of the coronary arteries leading
to dilated cardiomyopathy without evidence of ischemia.
CASE PRESENTATION: A thirty one year old male presented to ER with hemoptysis for one day. Patient
had no shortness of breath and no significant past medical history. CT angiogram of the chest revealed
right lower lobe pulmonary embolism with multiple right lower lobe pulmonary infarcts. Anticoagulation
initially started with IV heparin was discontinued later due to worsening hemoptysis. Vitals signs were
stable except a temperature of 99F. A transthoracic echocardiogram (TTE) showed EF of 25% and left
ventricular enlargement. The following day he complained of right arm numbness. MRI of the brain
revealed multiple small acute and sub-acute infarcts at various levels. Hypercoagulable state work up
was positive for lupus anticoagulant. Bilateral lower extremity duplex was negative for deep vein
thrombosis. A bronchoscopy obtained later showed extensive bleeding. Evaluation for various
autoimmune/connective tissue disorders and infections was also negative (including ANA and DS DNA).
Patient later improved after treatment with steroids, heparin and cyclophosphamide. TTE obtained two
months later showed improved ejection fraction with decreased left ventricular size.
DISCUSSION: Our case depicts a young male with acute ischemic infarcts of the brain, pulmonary
embolism and dilated cardiomyopathy with a persistently positive lupus anticoagulant, highly suggestive
of CAPS. Treatment revolves around stemming the ‘cytokine storm’. Early diagnosis and aggressive
therapy are essential because of extremely high mortality. Therapeutic management includes heparin,
high dose steroids, cyclophosphamide, plasma exchange, intravenous immunoglobulin and prostacyclin.
However a number of patients are refractory to treatment. Recent case reports show that the use of
Rituximab (Anti B Lymphocyte antibody), Defibrotide (Anti coagulant) and Eculizumab (Anti C5 antibody)
have been effective in these refractory cases.
397

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Hina Khan, MD
A case of Paroxysmal nocturnal hemoglobinuria (PNH) resembling Thrombotic thrombocytopenic
purpura (TTP): A diagnostic dilemma
Hina Khan, MD Second Author: Namita Gupta, MD Third Author: Huichun Zhan, MD
INTRODUCTION:PNH is a rare hematologic disease that presents with protean manifestations. It arises
from an acquired mutation in the PIG-A gene in hematopoietic stem cells, leading to decreased synthesis
of glycosylphosphatidylinositol anchors that bind to complement regulatory proteins. This causes
increased susceptibility of red cells to complement mediated intravascular and extravascular hemolysis.
We present a rare case of denovo PNH, posing as a diagnostic dilemma.
CASE PRESENTATION: A 25-year-old African American male presented with worsening bilateral
pleuritic chest pain and occipital headache of 3 days. He had fever up to 103F, dark urine and yellowish
discoloration of eyes a week before presentation. He also noticed blood in stools and bleeding gums. He
endorsed generalized weakness, fatigue, chronic intermittent headaches and shortness of breath on
exertion for last 4 months. Physical exam revealed pallor, icterus and mild splenomegaly. Laboratory
tests revealed pancytopenia [WBC count: 3400/cumm, Hb: 9.0 mg/dl, platelet count: 37,000/cumm],
indirect hyper-bilirubinemia, low haptoglobin levels and elevated LDH levels [373 u/l]. The peripheral
smear revealed schistocytes, macrocytic cells and increased reticulocytes. At this time a
microangiopathic hemolytic process was high on the differential diagnosis. With negative Coomb’s test,
suspicion for TTP was high. He met three of five classic symptoms in the TTP pentad and was started on
plasmapheresis. No improvement in pancytopenia was observed after multiple days of plasmapheresis.
Further testing revealed sickle cell trait. G6PD levels and ADAMS TS-13 activity levels were reported
normal. Bone marrow biopsy showed marked erythroid hyperplasia with decreased myelocytic and
megakaryocytic elements. Flow-cytometry and cytogenetics were unremarkable. CT scan performed in
an attempt to rule out occult malignancy, revealed right lower lobe pulmonary embolus and
splenomegaly. At this point, suspicion for PNH surfaced. PNH clones were seen in RBC [4.5% PNH III RBC]
and WBC [17% monocytes and 2% granulocyte] with 95% CD59+ cells. Patient was started on steroids
and later eculizumab with improvement in pancytopenia and resolution of pulmonary embolism.
DISCUSSION: PNH is an acquired defect in complement cascade leading to chronic intravascular
hemolysis with acute episodes, hemoglobinurea, pancytopenia and thrombosis. Venous thrombosis is
seen in 85% of PNH patients. PNH may arise denovo or in association with acquired aplastic anemias.
Since the clinical picture may overlap with other macroangiopathic hemolytic processes, initial diagnosis
may present as a diagnostic dilemma and often lead to fatal outcomes from thrombosis. Above case
emphasizes the importance of clinical suspicion for PNH in unexplained cytopenias and thrombosis. To
our knowledge, this is also amongst the rare cases of PNH with sickle cell trait, which may also have
contributed to increased risk of thrombosis.
398

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sharad Kothari, MD
Effectiveness of virtual reality gaming technology using Wii® in maintaining function in the elderly: a
pilot study.
Sharad Kothari MD, Aristotle Cochan MD, Gokulan Ratnarajah MBBS, John Maese MD, Donna Seminara
MD, Jack D’ Angelo MD, Anita Szerszen MD. Department of Geriatrics, Staten Island University Hospital,
Staten Island, NY
INTRODUCTION: The Wii® game-system provides the patient with a real world experience during their
physical therapy sessions. This kind of virtual reality may motivate patients to complete exercises and
provide a positive feedback to improve their performance. The utility of virtual reality game consoles
had been studied in children and adolescents with cerebral paralysis and shown to improved adherence,
exercise repetition, endurance and visual-perceptual processing. A recent meta-analysis concluded that
virtual reality may be a potential and safe tool for stroke rehabilitation. The aim of the study is to assess
the utility of virtual reality gaming console Wii® in maintaining the level of function in people age 80 and
above.
CASE PRESENTATION: Method: This prospective, interventional pilot study assessed the functional
performance as measured by the Functional Independence Measure (FIM) and Fall Risk Assessment
(FRA) scores. We enrolled 10 men and women who were referred for physical therapy at an outpatient
rehabilitation center. These patients underwent a supervised exercise regimen using a Wii® Fit program
consisting of three 30-minute exercise sessions per week for total of 6 weeks. FIM TM scores and FRA as
measured by the Biodex Balance System were measured at the initial visit and at completion of the 6week
program. The FIM score assesses areas of dysfunction in activities of daily living. Eighteen
variables were graded using a seven-point scale and the level of independence was measured as follows:
1-total assistance, 7-total independence. Maximal possible score was 126 points.
The Biodex Balance System assesses neuromuscular control and estimates fall risk by quantifying the
ability to maintain unilateral and bilateral postural stability on either a static or unstable surface. FRA
scores higher than age dependent normative values suggest further assessment for lower extremity
strength, proprioception, and vestibular or visual deficiencies. For patients aged 80 years and above, the
normal FRA ranges from 1.6 - 3.5. A lower score indicates less fall risk.
Results: 7 out of 10 patients completed the program. Mean FIM TM scores were maintained throughout
the duration of the intervention and remained unchanged at completion of the exercise program as
compared to the initial assessment (125.4). Mean score of the Biodex FRA decreased from 2.6 to 2.2 at 6
weeks of therapy.
DISCUSSION: A virtual reality gaming console, such as Nintendo Wii® may be an effective mode of
home-based physical therapy for elderly patients in maintaining their functional status.
399

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Grace N LaTorre, DO
A CASE OF ADULT LEFT PULMONARY ARTERY AGENESIS THAT ALSMOST WENT UNDIAGNOSED
Grace N LaTorre, DO, Ali Chaudhry, MD, Urmila Shivaram, MD
INTRODUCTION: Unilateral pulmonary artery agenesis (UPAA) is a rare condition commonly associated
with other congenital defects, such as Tetralogy of Fallot, atrial septal defect, coarctation of aorta, right
aortic arch, and Eisenmenger’s syndrome when detected early in life. In these cases the left pulmonary
artery is more often absent. Isolated UPAA is more commonly seen in adults and usually affects the right
pulmonary artery. These patients are usually asymptomatic and are diagnosed accidentally after routine
chest radiography or after presenting with non-specific symptoms such as respiratory tract infections,
shortness of breath and hemoptysis.
CASE PRESENTATION: A 54 year old African American female was admitted to our hospital with
complaints of worsening of dyspnea on exertion & orthopnea. The patient’s symptoms initially
presented three years ago and she underwent extensive evaluation including sleep studies, chest
radiography, CT scan of chest and coronary catheterization leading to the diagnosis of sleep apnea and
COPD. The patient was in good condition most of her life, with 3 term pregnancies finished with normal
deliveries. She also supported elective bariatric surgery without complications. Physical exam revealed a
morbidly obese women, with mild distress secondary to shortness of breath; chest and heart exam
showed marked scoliosis of the thoracic spine with decreased bilateral breath sounds, normal hearts
sounds and no murmurs; extremities with bilateral lower extremity edema. On this admission, CT scan
of the chest interestingly revealed absence of the entire left pulmonary arterial system with marked
hypoplasia of the left lung and evidence of chronic right heart strain. Echocardiogram showed severe
pulmonary hypertension, severe right atrial and right ventricular enlargement with decreased systolic
function. The patient was medically managed for fluid overload and pulmonary hypertension and as her
disease progress she was later referred to Columbia University for further management of her right
heart failure and heart & lung transplant evaluation. We concluded that the patient’s pulmonary arterial
agenesis with pulmonary hypoplasia overtime led to this patient’s severe dextro-scoliosis and the
development of pulmonary hypertension which both then resulted in her right heart failure.
DISCUSSION: As previously mentioned UPAA is a rare condition with an estimated prevalence of 1 in
300, 000. Approximately 170 patients with this disease have been described in the literature. UPAA
may remain asymptomatic or misinterpreted for many years; the unspecific clinical signs may lead to
late diagnosis and in some cases diagnosis may not be reached even after repeated imaging, as
described in our case. The latter may be because the anomalies observed are attributed to old
infections. Failure to recognize the malformation may lead to inappropriate treatment and delayed
surgical intervention. In conclusion, it is important to suspect UPAA in patients presenting with nonspecific
respiratory symptoms accompanied with chest x-ray findings such as decrease in size of the
affected hemithorax and compensatory hyperinflation of the contralateral hemithorax, elevation of
ipsilateral diaphragm and ipsilateral shift of mediastinum and/or absence of pulmonary artery shadow
or pulmonary markings on the affected side.
400

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Philippe Leveille
Secondary Hypertrophic Pulmonary Osteoarthropathy in the setting of Primary Lung Adenocarcinoma
and Latent Mycobacterium Tuberculosis Infection: A Case Report
Philippe Leveille, M.D., Kim John D.O., Olga Filipova, M.D., Julie Kanvesky, M.D., Mark Sonneschine, D.O.
INTRODUCTION: Hypertrophic Pulmonary Osteoarthropathy (HPOA) is a rare syndrome characterized
by digital clubbing, synovitis with arthralgias, and periostosis of the tubular bones. Although HPOA has
been known for more than 100 years, it remains poorly understood. Previously, both tuberculosis
infections and primary lung malignancies have been individually reported to be associated with the
syndrome. We present a case where a positive PPD screening was found to coexist with an underlying
malignancy in the setting of hypertrophic pulmonary osteoarthopathy.
CASE PRESENTATION: A 37-year-old, male, Honduran construction worker presented with a 3-month
history of symmetric diffuse arthralgia, fever, night sweats, weight loss and digital clubbing. He was
found to have a positive PPD and was admitted for further management. Chest X-ray showed evidence
of pulmonary disease. Work-up for active tuberculosis was negative, but revealed a primary left upper
lung, unifocal, adenocarcinoma with neuroendocrine features. The tumor size was noted to be 5.0 x 2.8
x 2.6 cm, with no mention of a scar cancer. His social history was negative for smoking; and further
history was unremarkable for risk factors. Incidental findings during his admission included a silent
pneumothorax and a microcytic anemia. A staging PET-CT scan failed to reveal metastatic disease, thus
the patient was indicated for tumor resection. The patient underwent primary surgical treatment with
tumor resection by lobectomy without complications. Subsequently, the patient underwent adjuvant
chemotherapy and radiation therapy for his malignancy and tolerated it well.
DISCUSSION: This case may indicate the possibility of an association between the three
diagnoses: latent tuberculosis, primary lung adenocarcinoma, and HPOA. This patient was without risk
factors for malignancy, with a diagnosis of latent tuberculosis and a clinical manifestation of
HPOA. While it is possible that the concurrent finding of a positive PPD in our patient was merely
incidental alongside his primary lung malignancy, the previously noted association of tuberculosis
infections with hypertrophic pulmonary osteoarthropathy makes this case notable. It would be
plausible to check acid-fast bacillus (AFB) smears of patients with initial diagnoses of primary lung
adenocarcinoma presenting with HPOA to search for clues for the pathophysiology of the
syndrome. This may help guide treatment for patients who do not have primary resection as a
treatment option.
401

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Vivek A Lingiah, MD
HIGH ALTITUDE HYPOXIA AND SPLENIC INFARCTION
Vivek A Lingiah, MD Additional Authors: Kwen Ortega MD, Madeeha Khan MD, Prasanta Basak MD,
Stephen Jesmajian MD
INTRODUCTION: Sickle cell anemia is characterized by abnormal hemoglobin molecules that deform
and aggregate under deoxygenated conditions. Splenic infarction, or autosplenectomy, occurs in these
patients after repeated vaso-occlusion of the splenic microvasculature. The etiology of these vasoocclusive
crises is usually secondary to dehydration, infection, or hypoxia. However, high altitudes can
also precipitate this condition. We present a case of splenic infarction in a patient after an airplane
flight.
CASE PRESENTATION: A 25 year-old male came to the ED with a 2 day history of left upper quadrant
(LUQ) pain. He had recently flown 12 hours, and complained of abdominal pain since his return. The
pain was associated with fever and chills. He took no home medications and had a history of sickle cell
trait, without any painful crises since childhood. He denied smoking or drug use, and socially drank 1-2
beers on weekends. On exam, he was in painful distress. Blood pressure was 154/91, pulse 118,
respiration 20, temperature 98.8F and saturation 99% on room air. Breath sounds were clear. There was
LUQ tenderness with mild guarding but no rebound tenderness. WBC was 18 and H/H was 12.1/37.4.
Chemistry panel was normal, but D-Dimer was high (1301). Chest CT and lower extremity dopplers were
negative for PE and DVT. CT abdomen showed considerable inflammation, consistent with splenic
infarction. Blood cultures came back negative. Hemoglobin electrophoresis showed elevated
Hemoglobin S (HbS) and Hemoglobin A2 (HbA2) (66.7% and 8.2%, respectively), confirming sicklethalassemia
trait. The patient was started on ceftriaxone, IV fluids, supplemental oxygen and analgesics,
with improvement in WBC count, fever and pain. He followed up with his hematologist, and was advised
to avoid flying without supplemental oxygen.
DISCUSSION: Airplanes usually fly at 35,000 feet. The aircraft cabin is pressurized, bringing the partial
pressure of oxygen to what it would be at 8000 feet. At this altitude, there is about 25% less oxygen in
the air than at sea level. With this decrease in oxygen, sickling of red cells could occur, especially in
patients with higher percentages of HbS. Splenic crisis has been reported to occur in 4.3% of patients
with Hb SS and in 23.5% patients with Hb S B-thalassemia after airplane travel. These patients should be
aware of complications that can arise at high altitudes, and physicians should evaluate them for the
need of in-flight supplemental oxygen.
402

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Akshiv Malhotra, MBBS
Bing Neel Syndrome- A Rare Complication of Waldenstrom’s Macroglobulinemia
Akshiv Malhotra, MBBS Others: Toni Pacioles, MD Teresa Gentile, MD
INTRODUCTION: Bing Neel (BN) syndrome is a very rare complication of Waldenstrom’s
Macroglobulinemia (WM) that should be considered in patients with neurologic symptoms and a history
of WM. Neurologic complications occur in 25% cases of WM, but are most commonly due to serum
hyperviscosity syndrome and immune related neuropathy. Direct malignant lymphoid infiltration of the
CNS, the so called Bing Neel syndrome is extremely rare.
CASE PRESENTATION: 70 year old female presented to the Emergency Department(ED) with
worsening left upper extremity weakness, dysarthria and confusion.
Her past medical history was significant for WM diagnosed 1 year ago, breast cancer diagnosed 11 years
ago, status post lumpectomy, radiation and Tamoxifen. About a year ago, she was noted to have anemia
and paraprotein in her blood and underwent a bone marrow biopsy which showed a lymphoplasmacytic
infiltrate. She then underwent CT scans to look for enlarged lymph nodes. She was found to have a mass
of the left kidney which on biopsy showed Lymphoplasmacytic lymphoma with an IgM monoclonal
protein (WM). She was treated with 4 cycles of Rituximab to which she responded well. However, she
started having intermittent confusion and balance problems and now, presented to the ED with left
upper extremity weakness, dysarthria and confusion. The patient was admitted to the neurology service.
The symptoms resolved within 6 hours of onset. She underwent CT of the head without contrast which
showed no evidence of acute bleed or infarct. MRI of the brain showed dural enhancement. Lumbar
puncture was performed which showed Protein of 768 mg/dl and White count of 108/cu mm with 100%
monocytes. The cytopathology report and flow cytometry came back consistent with previously
diagnosed B cell lymphoma ( Lymphoplasmacytic lymphoma). Dexamethasone 4 mg every 6 hours was
started. An intraventricular reservoir was placed and intrathecal Methotrexate was started twice a week
for 8 cycles. The CSF cleared up with no evidence of malignancy. She was then treated with craniospinal
irradiation and has remained in remission for 4 months.
DISCUSSION: BN syndrome is defined as WM with perivascular infiltration of small lymphocytes,
lymphoplasmacytoid cells, and plasma cells in the CNS. BN syndrome refers specifically to the
involvement of perivascular infiltrates rather than stroke or hemorrhage due to hyperviscosity.
Symptoms may include seizures, confusion, cognitive decline, headache, blurry vision, pain, numbness,
paresthesias, hearing loss, or weakness. Serum laboratory tests show macroglobulinemia, normocytic
anemia, IgM kappa or lambda light chain restriction. CSF analysis shows lymphocytic pleocytosis of 100-
500 cells/cu mm, elevated protein 40-2000 mg/dl and CD20+ lymphoplasmacytoid cells in flow
cytometry and cytology. MRI shows T2/FLAIR hyperintensity and gadolinium enhancement. Remission
in BN syndrome has been reported with the use of intrathecal Methotrexate alone, or with radiation
therapy.
403

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Akshiv Malhotra, MBBS
THE G.I.S.T. OF NEUROFIBROMATOSIS
Akshiv Malhotra, MBBS Others: Jonathan Wright, MD Ajeet Gajra, MD
INTRODUCTION: Neurofibromatosis type 1 (NF1) , also known as Von- Recklinghausen’s disease is
amongst the most commonly transmitted hereditary autosomal dominant diseases, with an estimated
birth incidence of 1:3,000. Loss of NF1 tumor suppressor gene on chromosome 17 leads to the
development of benign and malignant tumors in NF1. In addition to cutaneous, soft tissue, and visceral
(plexiform) neurofibromas, this syndrome is associated with several types of gastrointestinal (GI) and
abdominal tumors. Here we present the case of a patient with NF1 who was incidentally found to have
an extraintestinal Gastro-Intestinal Stromal Tumor (GIST).
CASE PRESENTATION: A 64-year-old man with known NF1 during preoperative workup for a CABG was
incidently noted to have a large inhomogeneous pelvic mass with dimensions of 9 cm x 10 cm x 7.8 cm
on a CT abdomen/pelvis. Biopsy of the mass showed palisaded appearing long spindle cells. On
immunohistochemical testing, S-100 was negative (ruling out schwannoma) and there was strong and
diffuse positivity for CD117( KIT) and CD34 indicating a GIST.
The tumor was considered to be marginally resectable, so neoadjuvant treatment with Imatinib 400 mg
daily was started to decrease the tumor size preoperatively. After three months on the repeat CT
abdomen/pelvis multiple foci of air were seen in the mass, suggestive of necrosis though the size
remained stable at 11 X 9.7 X 7.7 cm. His tumor was then surgically resected en-bloc. Large cavity was
noted within the tumor along with fistula formation necessitating partial excision of small intestine.
After the surgery he was restarted on Imatinib 400 mg daily for 36 months
DISCUSSION: Extra-intestinal GIST is a very rare entity, accounting for < 5% of cases of GIST. There is a
known correlation between NF1 and GIST. GIST develops in 7% of patients with NF1, although the
incidence of GIST in the general population is 1.5/100,000/year. NF1 patients tend to develop GIST at a
younger age (median 49 years) than sporadic GIST (56 years). This brings forward a need to formulate
guidelines to screen for GIST in patients with NF1 at an earlier age. GIST may be associated with
gastrointestinal bleed, perforation or obstruction as demonstrated by pathological findings in our case.
Imatinib has greatly enhanced outcomes in patients with GIST.
404

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sandhya Manohar, MD
AN UNUSUAL CAUSE OF HEADACHE
Sandhya Manohar, MD Marie Louies Lamsen MD, Prasanta Basak MD, Stephen Jesmajian MD. Sound
Shore Medical Center of Westchester and New York Medical College.
INTRODUCTION:Colloid cysts are benign congenital tumors that usually arise from the anterior third
ventricle,
posterior to the foramen of Monro. These cysts have also been reported to frequently arise in
the septum pellucidum, the fourth ventricle, and the sella turcica. They are usually filled with
gelatinous material and cholesterol crystals. The epithelium lined cysts may lead to acute
obstructive hydrocephalus, increased intracranial pressure, and rarely, intracystic hemorrhage.
Approximately 0.5-1% of all primary brain tumors and 15-20% of all intraventricular masses are
colloid cysts.
CASE PRESENTATION: A 46 year old female came to the ER complaining of severe headaches for 4
days. Her
headache was localized to the top of her head, with radiation to the back of her neck. She
described the headache as pressing, 8-9/10 intensity, lasting from minutes to hours, and
aggravated by stress. She found partial, relief with Ibuprofen and heating pads. There was no
associated nausea, photophobia, tinnitus, vertigo, or weakness. There was no prior history of
severe headaches or migraine. On examination she was anxious, not in any distress, with BP
98/63, pulse 88/min, RR 18/min, temp 97.8F and Spo2 99%. Neurological examination including
fundoscopy was normal. Her routine blood work was unremarkable. A CT head without contrast
showed an 8.5mm rounded circumscribed hyperdense structure in the region of foramen of
Monro, most consistent with a colloid cyst, along with enlargement of the left lateral ventricle
and transudation of fluid, suggestive of periventricular interstitial edema. Neurology was
consulted and she was referred to a neurosurgeon for cyst removal.
DISCUSSION: Although these tumors are considered congenital, their presentation in childhood is rare.
The
tumors are usually symptomatic in patients aged 20-50 years. With the advent of CT scanning
and MRI, the number of diagnosed asymptomatic colloid cysts has increased. Though there
was dilatation of the lateral ventricle, our patient did not have symptoms suggesting normal
pressure hydrocephalus (eg, dementia, gait disturbance, urinary incontinence). If patients are
too ill to tolerate surgical resection, cerebrospinal fluid diversion, often requiring bilateral shunts,
may be considered. Our case highlights the importance of a head CT in late onset persistent
headaches.
405

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sandhya Manohar, MD
EIKENELLA CORRODENS: A RARE CAUSE OF SEPTIC ARTHRITIS OF THE HIP
Sandhya Manohar, MD Diana De Jesus MD, Esther Kwon, Prasanta Basak MD, Jeffrey Lederman MD,
Stephen Jesmajian MD. Sound Shore Medical Center of Westchester and New York Medical College.
INTRODUCTION:Over 90% cases of septic arthritis are due to Staphylococci or Streptococci infections.
Septic arthritis with Eikenella corrodens as the etiological organism has been rarely reported. The
pathogenesis is usually a “fight bite” injury to the hand or the metacarpal phalangeal joint, through
which the organism gets inoculated. We present a case of septic arthritis with Eikenella corrodens and
Streptococcus intermedius, without an obvious portal of entry.
CASE PRESENTATION: 66 year old female complained of severe lower back pain. The pain was
constant, rated 10/10, radiating down the left leg and worsened by movement. There was no history of
trauma or recent dental work. She did not complain of weakness, sensory symptoms or incontinence.
On admission, she was afebrile but tachycardic at 107bpm, with BP of 147/98 mm Hg. She had restricted
range of movement, on the left leg due to extreme pain. The left groin was tender to palpation. The rest
of the physical exam including neurologic exam was unremarkable. Laboratory tests showed WBC
17000/cu mm, with polymorphs of 80. Chemistry panel was normal. CXR was negative. Lumbosacral
spine MRI showed unremarkable age related changes. Pelvic MRI showed moderate left hip joint
effusion with adjacent medial muscle edema. On the second day of admission she developed a fever of
101.5F. Blood cultures were sent. CT guided aspiration of the left hip joint was done. The joint fluid
showed protein 3 g/dl, glucose 16 mg/dl, WBC 214,500/cu mm with gram stain showing both gram
positive cocci and gram negative bacilli. Empiric treatment with Ceftazidime and Vancomycin was
started. Transthoracic echocardiogram showed hyperdynamic LV, and no vegetations. Cultures from
joint fluid grew Streptococcus intermedius and Eikenella corrodens. Blood cultures grew Streptococcus
intermedius. She was advised to undergo a trans esophageal echocardiogram, but the patient refused
any further work up. A PICC line was inserted and IV ceftriaxone given for 4 weeks followed by 4 weeks
of oral antibiotics.
DISCUSSION: Both Eikenella corrodens and Streptococcus intermedius are commensals of the human
mouth and upper respiratory tract. There appears to be an association between Streptococcus and
Eikenella corrodens, which seem to frequently co-infect. Mixed infection with these organisms causes an
exponential increase in growth, as compared to an infection with Eikenella alone. To the best of our
knowledge, this is the first case report of Eikenella septic arthritis of the hip without an obvious port of
entry.
406

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Maryah Mansoor
LYMPHANGIOLEIOMYOMATOSIS (LAM) or PULMONARY LANGHERHANS CELL HISTIOCYTOSIS (PLCH)? A
CHALLENGING DIAGNOSIS.
Maryah Mansoor Scott Pompa Thomas Kilkenny Maryah Mansoor
INTRODUCTION: CASE PRESENTATION: A 24 year old Caucasian woman presented with diffuse left
sided chest pain and shortness of breath. The pain was sharp, non-radiating, pleuritic, and began acutely
while sitting at her computer. Patient reported a chronic nonproductive cough. The patient had a 5 pack
year smoking history. Her past medical history was significant for asthma since the age of 13. Family
history was unremarkable. The patient’s oxygen saturation was 96% on room air and EKG showed sinus
tachycardia. Lab work including complete blood count and metabolic profile was within normal limits
(WNL). Chest X-ray (CXR) showed interstitial lung disease, bilateral pneumothorax, left greater than
right. The patient was kept on 100% non rebreather. A left side pig tail catheter was placed with
continuous suction and later due to expansion of the right sided pneumothorax a right sided pigtail
catheter was placed. High resolution computed tomography (HRCT) of he chest was performed, which
demonstrated diffuse bilateral spherical and lobulated thin wall cysts consistent with
lymphangioleiomyomatosis (LAM). An autoimmune workup for lupus and a1-antitrypsin deficiency was
negative. Renal ultra sound and echocardiogram were WNL. Based on the presentation and HRCT,
primary diagnosis of LAM was made. The patient was stabilized in the ICU and was later transferred to
the city's LAM center. Lung biopsy was performed at the LAM centre revealed a definitive diagnosis of
Pulmonary Langherhans Cell Histiocytosis (PLCH).
DISCUSSION: PLCH and LAM are rare lung diseases with unknown incidence and prevalence; both
diseases affect young adults and Caucasians most frequently. PLCH predominately affects patients aged
20 to 40 with equal gender distribution while LAM affects women of childbearing
age. HRCT findings both diseases show multiple cysts, while PLCH may also have nodules with middle to
upper lobe predominance and interstitial thickening. Due to these similarities it is often challenging to
diagnose these disease entities clinically. Hence tissue confirmation by biopsy with immunostaining is
required for definitive diagnosis. Being uncommon, both LAM and PLCH are often misdiagnosed as
asthma and treated with bronchodilators untill the patient presents with complications (as in this case).
Recurrent pneumothorax, pulmonary hypertension, diabetes insipidus, and malignancy are common
complications of PLCH. Where as complications of LAM include spontaneous pneumothorax,
chylothorax, chylopericardium. The treatment for PLCH should focus on smoking cessation.
Immunosuppressive therapy such as glucocorticoids and cytotoxic agents are of limited value. No
therapy has been proven beneficial for the treatment of LAM, however lung transplant should be
considered in advanced progressive disease.
LAM and PLCH although being rare should be considered a differential diagnosis in patients with
spontaneous bilateral pneumothorax.
407

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Maryah Mansoor
BACK PAIN FROM THE TROPICS
Maryah Mansoor Ayesha Siddiqui Neville Mobarakai Maryah Mansoor
INTRODUCTION: CASE PRESENTATION: A 47 year old lady was sent to our institution by her PMD for
evaluation of ataxia, gradually worsening bilateral leg weakness and numbness for 3 years. She also
reported low back pain, paraesthesia of legs, progressive urinary incontinence and constipation. The
patient had no history of trauma, fever, headache, seizure or other neurological symptoms. Review of
other systems was negative. The patient had no significant family history, sick contacts or any drug
abuse. Her back pain was only partially relieved with analgesics. Her vitals were stable. Neurological
exam was significant for decreased power in both lower extremities (3/5) with spasticity, hyper reflexia
and non sustained ankle clonus. Gait was unsteady. Anal sphincter tone was normal. Rest of the
neurological exam was normal.
Further workup was pursued to rule out demyelination, infectious, inflammatory or autoimmune
etiology. Investigations revealed normal hemogram, serum chemistry, vitamin B12, folate level, HbA1c
and urinalysis. ESR was 8mm/hr; rheumatoid factor, RPR, anti nuclear antibody, ACE levels, lyme
serology and antiphospholipid antibody were negative. CSF analysis was normal. MRI brain, cervical,
thoracic and lumbosacral spine was unremarkable for myelopathy or demyelination.
On further inquiry, patient revealed that she was originally from Ecuador and had settled in USA for 20
years. Serum Human T cell lymphotropic virus type 1 (HTLV1) serology was also sent which came back
positive. Patient was offered an HIV test which she declined.
Based on the clinical picture and serology, diagnosis of tropical spastic paralysis (TSP) or HTLV1
associated myelopathy (HAM) was made. The patient was started on a short course of high dose
intravenous steroids followed by oral prednisone taper. The patient was then referred for in-house
rehabilitation with which she made gradual progress over a few months.
DISCUSSION: There are various pathologies that affect the spinal cord including traumatic, vascular,
autoimmune, neoplastic or infectious etiologies. Human T-cell lymphotropic virus type I (HTLV1) is
known to cause adult T cell leukemia/lymphoma and slowly progressive neurological disease called
HTLV1 associated myelopathy (HAM) or Tropical Spastic Paralysis (TSP) comprising of spastic paraparesis
and urinary disturbance. It is characterized by inflammation of spinocerebellar, corticospinal and
spinothalmic tracts with relative sparing of the posterior columns. HAM/TSP is endemic in Japan,
Caribbean, South America, Middle East, but comparatively rare in USA hence is often overlooked. There
is no definite treatment recommended for this disease, however steroids with their anti inflammatory
effects are thought to be useful. While trauma, vascular, neoplastic entities are common causes of back
pain with bowel and bladder malfunction, Tropical Spastic Paralysis (TSP) should be considered a
differential diagnosis in immigrants from South America, Japan and other tropical areas.
408

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Carlos Martinez-Balzano,
MD
Blood pressure roller coaster: pheochromocytoma presenting with cyclic hypertensive crises and severe
hypotension.
Carlos Martinez-Balzano, MD. Robert Carhart, MD.
INTRODUCTION: Cases of pheochromocytoma presenting with severe hypotension are extremely rare
and their adequate management is unclear.
CASE PRESENTATION: A 59-year-old Caucasian man presented with palpitations, diaphoresis,
headache, nausea, and musculoskeletal pain. During examination, he had two cluster episodes with
tachycardia (130 bpm) and hypertension (200/110 mmHg); he was also hyperreflexic and had
orthostatic hypotension. He was admitted for a suspected pheochromocytoma. EKG showed sinus
tachycardia without ST-segment changes. Echocardiogram demonstrated hyperdynamic ventricles and
low EF (20-25%) thought to be secondary to tachycardic cardiomyopathy. BMP showed acute kidney
injury with a BUN:creatinine ratio > 20:1 caused by kidney hypoperfusion and possible volume
depletion. Treatment with IV normal saline (100 mL/h) and labetalol was started. Abdominal CT showed
a large tumor in the right adrenal gland. Overnight, severe hypotension occurred (68/40 mmHg) which
barely responded to 6L of IV fluids and required IV phenylephrine infusion. Intubation for airway
protection was done. CK, CK-MB and troponin-T returned elevated and heparin infusion was started.
Subsequent echocardiogram showed a normal EF without akinetic areas confirming the suspicion of
tachycardic cardiomyopathy and suggesting that the elevated CK-MB and troponin were systemic in
origin. During the next 2 days, cyclic episodes of hypertensive crisis followed by hypotension occurred,
and were treated with IV phentolamine infusion or pressor support, respectively. After that interval,
fluctuations stopped and the pattern changed to persistent hypotension. Phenylephrine was slowly
tapered and after 4 days was not required. The patient was awake and without major neurologic
sequelae after extubation. A 24h urine collection revealed norepinephrine and epinephrine levels of 687
µg and 1829 µg. Doxazosin and metoprolol were started and the patient was discharged home. One
week after, he underwent surgery with excision of the pheochromocytoma with multiple necrotic areas,
confirmed by histology.
DISCUSSION: Pheochromocytoma can cause orthostatic hypotension, however, severe
hypotension is very rare and few cases have been reported. A cyclic pattern of severe hypertension and
hypotension has been seen in these cases which were all caused by epinephrine-secreting tumors. The
hypothesis is that excessive epinephrine release leads to decreased circulating volume and
vasoconstriction which decrease cardiac output and cause further catecholamine release. The resultant
hypertension activates the baroreceptor reflex causing a hypotensive response which is worse in the
setting of contracted volume. Another hypothesis is that tumor necrosis leads to massive catecholamine
release followed by acute withdrawal causing hypotension, which could explain the persistent late
hypotensive phase in our patient. Our case describes an unusual and not well-understood clinical
presentation of pheochromocytoma. Furthermore, therapeutic recommendations for these cases are
obscure and require further research since they present with life-threatening complications.
409

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Carlos Martinez-Balzano,
MD
Campylobacter Fetus Bacteremia In A Young Healthy Adult Transmitted By Khat Chewing
Carlos Martinez-Balzano, MD. Patrick J. Kohlitz, MD. Preeti Chaudhary, MD. Housam Hegazy, MD.
INTRODUCTION: Campylobacter fetus is a pathogen affecting almost exclusively patients with
immunosuppression and chronic debilitating diseases. We report the case of a healthy young man with
C. fetus bacteremia presenting with fever, hypotension and meningitis.
CASE PRESENTATION: A 28-year-old healthy man presented with fever, chills, decreased appetite,
night sweats, diarrhea and headache with photophobia for two days. He was a college student in an
urban setting without any recent travel history. Physical examination revealed mild dehydration. CBC
and stool examinations were normal. CSF analysis showed lymphocytosis (170 x 10 9 cells/L) with normal
protein and glucose levels. He was discharged home receiving symptomatic treatment. After two days,
the blood cultures were growing gram-negative rods and the patient was called back to the hospital. He
had hypotension that was managed with intravenous fluids. Endocarditis was ruled out by TEE. CSF
cultures and viral tests were negative. Phenotypic properties of the bacteria growing in four separate
blood cultures drawn at different times, identified them as Campylobacter spp., confirmed as C. fetus
subspecies fetus by analysis of 16S rDNA sequence. Although CSF cultures were negative, we believe the
same microorganism caused the meningitis. Subsequent studies showed normal immunoglobulin levels
and negative HIV serology. The patient denied ingestion of undercooked food, unpasteurized milk,
contaminated water or close animal contact. He disclosed to be a frequent user of khat, which
represents the most likely source of transmission. The patient received ciprofloxacin and azithromycin
with adequate clinical improvement. After six months, he remains asymptomatic.
DISCUSSION: Campylobacter fetus commonly affects cattle and sheep. Systemic disease in humans
caused by this bacterium is severe and almost invariably associated with immunosuppression. Thus, C.
fetus bacteremia in immunocompetent adults is extremely rare and only four cases have been reported.
To our knowledge, this is the first case of C. fetus bacteremia in an immunocompetent man reported in
the USA and also the first one linked to khat use.
Khat is a plant that has been used for centuries in the Horn of Africa and the Arabian Peninsula. It
contains the alkaloid cathionine and is cultivated in circumstances that favor contact with animal feces;
its young leaves are picked freshly and transported in moist conditions to retain their potency. Our
patient chewed the leaves unwashed for many hours, likely introducing the bacteria into his
gastrointestinal tract. Khat is not associated with immunosuppression; to the contrary, it increases IL-2
production, total lymphocyte and CD4 counts, which suggest that our patient was not
immunocompromised by using it.
Our case suggests that C. fetus is a pathogen that can affect not only immunosupressed patients but
healthy individuals as well. Also, as new lifestyles are adopted, khat should be considered as a risk factor
for the introduction of infectious diseases.
410

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Asad Mohammad, DO
Gluteal Abscess Formation After Concurrent Intramuscular Steroid and Heroin Injection
Asad Mohammad, DO Second Author: Babak Tofighi, MD Third Author: Robert Graham, MD
INTRODUCTION:Over one million individuals in the United States, have or continue to use anabolicandrogenic
steroids. Abscesses and other related complications of intramuscular (IM) injection of
anabolic-androgenic steroids (AAS) have been well-documented in the literature. However cases of
concurrent use of AAS and heroin have yet to be reported. We present a case of abscess formation in a
29 year-old female physical trainer reporting daily injections of AAS and heroin mixtures for four
months.
CASE PRESENTATION: A 29 year old caucasian female presented to the emergency department
complaining of severe right buttock pain, described as a throbbing and burning sensation. Her symptoms
began approximately two days prior, become progressively worse to the point that she could barely
ambulate or move her right lower extremity. She noticed warmth, redness, and tenderness along the
right buttock area that had now spread to her proximal posterior thigh. She denied fevers or chills. She
did admit to regular injection of anabolic steroids and heroin into the right buttock area. Physical exam
revealed erythema, tenderness, edema, and warmth along the right buttock area. Some fluctuance was
also noted. CT scan of the pelvis revealed extensive subcutaneous edema of the lower back, and a large
fluid collection superficial to the right gluteus muscles measuring 8.1 x 4.1 cm consistent with an
evolving abscess. Edema extended inferiorly along the right gluteal region and lateral aspect of the
proximal thigh.
The surgery team performed an incision and drainage of the buttock abscess and she was discharged to
home with oral antibiotics. Cultures were sent to the lab, which eventually returned positive for MRSA.
DISCUSSION: Buttock injections of parenteral medications can sometimes result in the formation of
calcified granulomas, abscesses, vascular and nerve damage, and focal myopathies. Heroin injection has
been shown to cause the above pathologies, and the concomitant injection of both heroin and anabolic
steroids can also result in the similar complications. Such a combination may predispose patients to
abscesses by inducing soft-tissue ischemia exacerbated with nonsterile injection techniques. Education
and close clinic follow-up is needed to prevent complications among users. In addition, epidemiological
surveys of use patterns in athletes and trainers may help identify clusters at high risk of similar
complications.
411

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jose E Najul
Treatment of Hemosuccus Pancreaticus via ERCP: an uncommon but effective treatment
Najul, Jose E. MD Kim, Sang MD Gutierrez, Cristina MD
INTRODUCTION:Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleed (GIB). We
describe the case of a patient with HP who was successfully managed with ERCP, a failry uncommon
therapeutic approach.
CASE PRESENTATION: A 56-year-old female was admitted to our hospital with pancreatitis and
choledocolithiasis. ERCP with sphincterectomy and pancreatic duct stent placement improved her
symptoms at the time. Fourteen days after discharge, the patient presented with hematemesis,
hypotension, and hemoglobin of 5g/dl. Emergent upper endoscopy showed a clean papillotomy site, and
active bleeding from the pancreatic duct orifice. Hemostasis was attempted with epinephrine injection
and placement of Resolution clips. Post procedure the patient continued to have blood loss and
required multiple transfusions. Repeat CT angiograms failed to show any aneurysms of the hepatic or
splenic arteries or any other active bleeding sources. As embolization was not an option and surgery
was reluctant to pursue any intervention, including partial and/or total pancreatectomy, ERCP was
repeated. Active bleeding from aneurismal-like dilation of the pancreatic duct in the head of the
pancreas was observed. The pancreatic duct was injected with epinephrine and ballooned to
tamponade. When hemostasis was achieved, four pancreatic duct stents were deployed to maintain
hemostasis. One month after discharge, a repeat ERCP with Spyglass pancreatoscopy was performed to
determine the etiology of the HP. Pancreatoscopy revealed inflamed friable tissue in the pancreatic
duct. Biopsies revealed marked inflammation with erosion and granulation tissue with reactive
epithelial changes. There was no evidence of malignancy.
DISCUSSION: HP was first described in 1931 and accounts for 1.4% of upper GIB cases requiring
emergent endoscopy. Chronic pancreatitis, pancreatic malignancy, and pancreatic duct stones are
commonly associated. Embolization through angiography is usually the preferred treatment. In our case,
multiple angiograms failed to show the site of bleeding or aneurysms and a surgical approach was
deemed to drastic. Therefore, ERCP with the injection of epinephrine, tamponade with a balloon, and
placement of stents in the pancreatic duct was utilized and was successful.
HP is a rare cause of GIB and due to its scarce nature it can easily be overlooked and mistreated. It is of
utmost importance that internists work in coordination with other specialists in identifying, diagnosing,
and treating this pathology.
412

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Olabimpe Solape
Omobomi, MBChB
HOT Liver
Olabimpe Solape Omobomi, MBChB, Iandine Paras MD, Jacobo Hincapie MD, Susanna Curtis(Medical
student), Alexander Sy MD, Theodore Lennox MD
INTRODUCTION: Fever and hepatitis in immunocompetent adults are usually attributed to common
hepatotrophic viruses, namely hepatitis A, B and C. However, the less common viral hepatitides can also
cause severe hepatitis in immunocompetent adults.
CASE PRESENTATION: A 52-year-old female was admitted for intermittent fever for one week. This
was accompanied by generalized muscle pains, upper abdominal and back pains. She had a history of
hypoparathyroidism. Her vital signs were temperature 102°F, heart rate 100 beats per minute, blood
pressure 118/75mmHg and respiratory rate of 18 breaths per minute. The rest of her physical
examination was unremarkable. She had normal blood count, chemistry, chest x-ray and urinalysis. Her
liver enzymes were newly elevated, AST 739, ALT 955 and ALP 170, with normal bilirubin and
international normalized ratio. The acetaminophen and alcohol levels, hepatitis A, B, C and HIV
antibodies were negative. Hepatobiliary ultrasound, computerized tomography scans of the chest,
abdomen, pelvis and echocardiogram were normal. Following admission, she developed diarrhea and
was empirically treated with antibiotics pending stool studies. The diarrhea resolved spontaneously. She
continued to have temperature spikes ranging between 102 and 104 o F despite anti-pyretics. Blood,
urine and stool cultures yielded no pathogens. Work-up for non-infectious causes of hepatitis was
negative. Tests for less common viral hepatitis such as Herpes Simplex, Epstein Barr and
Cytomegalovirus were subsequently done. All were negative except for Cytomegalovirus IgM titer of
2.15 (normal value: 0.00-0.89) with Cytomegalovirus IgG titer of 0.08 (normal value: 0.00-0.90) and
positive Cytomegalovirus DNA qualitative PCR. She underwent liver biopsy which revealed inflammation
but no cellular necrosis and preserved architecture. She was discharged to clinic follow-up. One week
later her liver function had improved to AST 43, ALT 42 and ALP 120. Her fever spontaneously resolved.
Repeat titers of cytomegalovirus IgM and IgG after 2 weeks were 5.80 and 2.53 respectively.
DISCUSSION: Cytomegalovirus infection in apparently immunocompetent hosts is traditionally
regarded as a benign, self-limited illness. However, there have been several reports of severe
cytomegalovirus infections in immunocompetent hosts. Severe cytomegalovirus hepatitis has been
defined as a fivefold rise of ALT, jaundice or a degree of liver involvement requiring hospitalization.
Cytomegalovirus should be tested in immunocompetent adults who present with fever and unexplained
hepatitis. The role of antivirals in severe cytomegalovirus hepatitis in immunocompetent hosts remains
unclear. Randomized controlled studies need to be carried out
413

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Pramod Pantangi, MD
Bilateral empyema: A rare complication of Celiac Plexus Block.
Pramod Pantangi, MD Second Author:Praveen Sampath, MD
INTRODUCTION: Abdominal pain secondary to chronic pancreatitis is difficult to treat, with significant
proportion of patients having ongoing pain in spite of being on large dose opioid analgesics. Celiac
plexus block (CPB) was primarily developed to treat refractory pain, particularly in patients with small
ductal involvent where endoscopic decompressive techniques of pancreatic duct are of low yield. We
describe a case where a patient who underwent CPB, presented with bilateral empyema and
mediastinal collection from an extension of retro gastric retroperitoneal collection, which occurred as a
complication CPB.
CASE PRESENTATION: A 40-year-old female with history of chronic pancreatitis secondary to
gallstones, who had undergone a EUS guided CPB one month ago, presented to the ER with increasing
abdominal pain and fever. Clinical examination was unremarkable. Labs revealed white count of 16K
with normal pancreatic enzymes. CT of the abdomen showed a retro gastric retroperitoneal collection
near GE junction measuring about 7cmX5cm.She was started on imipenem. Subsequently, she
developed shortness of breath. Chest CT showed extension of the retrogastric collection into
medistinum and bilateral pleural spaces. Bilateral chest tubes were placed. Blood cultures were negative
and pleural fluid cultures grew Strep.milleri group. Her esophagogram did not show any ongoing leak.
She was managed conservatively and discharged with 6 weeks of IV antibiotics. Patient was
symptomatically much better and her white count normalized. Repeat CT scan after 6 weeks showed
complete resolution of pleural, mediastinal and retroperitoneal collections.
DISCUSSION: CPB involves injection of an anesthetic agent and steroid into the celiac plexus. EUS
guided CPB recently gained popularity secondary to better access to the celiac plexus. Different metaanalysis
report the complication rates at around 1.8-2%. Complications include post-procedural selflimiting
pain, hypotension and retroperitoneal abscess. There are only few case reports of empyema as
a complication of CPB. It can occur either as an extension from mediastinitis from perforation of
esophagus during procedure or as in our case, an extension from retroperitoneal abscess. Causative
flora can be polymicrobial or mostly Strep.milleri group, which are commensals in the GI tract.
Management generally includes IR guided drainage of the retroperitoneal abscess (if accessible), chest
tubes for empyema and antibiotics for at least 4 weeks. Small mediastinal and retroperitoneal
collections as in our case, resolve with drainage of empyema and IV antibiotics. Larger collections
require open drainage. EUS guided drainage is not recommended to avoid introducing further infection
and because of the risk of disseminating the infection into the peritoneal cavity.
414

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Resmi Premji, MD
RENAL TUBULAR ACIDOSIS, A RARE COMPLICATION OF BARIATRIC SURGERY
; Resmi Premji MD, Richa Aggarwal MD, Kameswari Lakshmi MD, Prasanta Basak MD, Stephen Jesmajian
MD
INTRODUCTION:Normal anion gap metabolic acidosis after bariatric surgery is often due to intestinal
bicarbonate losses. Renal compensation in this setting occurs by acidification of urine resulting in a low
urinary pH and negative urine anion gap. Here we report a patient who underwent bariatric surgery and
had normal anion gap metabolic acidosis but found to have a high urinary pH and positive urine anion
gap. We attribute these changes to type 1 renal tubular acidosis, a rare complication of jejunoileal
bypass surgery.
CASE PRESENTATION: A 39 year old female with history of multiple sclerosis and jejunoileal bypass
surgery 10 years ago, was brought to the emergency room with complaints of shortness of breath and
generalized weakness for one month. She had associated symptoms of nausea and vomiting for several
days. On examination, she was hypotensive (100/70 mm Hg) and tachycardic (120-130 bpm). Laboratory
data showed normal anion gap metabolic acidosis (Sodium: 147 mEq/L, Potassium: 3.0 mEq/L, Chloride:
134 mEq/L and CO2: 4.4 mEq/L) and normal renal function (BUN: 3mg/dL, Creatinine: 0.6mg/dL).
Arterial blood gas revealed pH: 7.16, PCO2: 18.9 mm of Hg, HCO3: 8.3 mEq/L and lactate: 2.6 mEq/L.
Urine pH was 6.0, urine sodium: 54 mEq/L, potassium: 30 mEq/L, chloride: 81mEq/L and urine anion gap
3.0. The high urinary pH and positive urine anion gap suggested the metabolic acidosis is due to renal
tubular acidification defects rather than induced by her vomiting. Patient was placed on bicarbonate
infusion, three ampoules of bicarbonate in D5W at 200 ml/hour for 2 days. Her hyperchloremia and
metabolic acidosis improved and weakness resolved, with no further episodes of nausea or vomiting.
DISCUSSION: The exact pathogenesis of distal RTA in bariatric surgery patients is not known. Some of
the proposed mechanisms are deposition of immune complexes in the tubules, and a causal association
with hyperoxaluria. In these patients there is impaired acidification of urine, and urine ammonium fails
to rise in the setting of acidosis. Ammonium is an unmeasured cation and a decrease in its excretion, as
NH4Cl leads to low urine chloride concentration, and therefore a positive urine anion gap and high
urinary pH. [Urine AG= Urine (Na+ K- Cl)]. Although bicarbonate replacement would provide temporary
benefit in these patients, the ultimate treatment would be a revision of the surgery. With bariatric
surgery becoming more commonplace, clinicians need to be aware of this potential late complication of
the procedure.
415

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Ameer Z Rasheed, MD
Seronegative Longitudinally Extensive Transverse Myelitis (LETM) mimicking Multiple Sclerosis (MS)
Ameer Z Rasheed, MD Wiswanath Vasudevan, MD Naveen Goyal, MD. Celinah Olalowo, MD.
INTRODUCTION:Neuromyelitis optica (NMO) is a rare but severe, debilitating disease that
predominantly features immunopathology in optic nerves and spinal cord sparing the brain white
matter. NMO has a rare variant, Longitudinally Extensive Transverse Myelitis (LETM) which
predominantly involves spine. We present a very rare case of LETM with brain white matter involvement
similar to Multiple Sclerosis.
CASE PRESENTATION: 59 y/o AA female presented with inability to walk, bilateral lower extremity
weakness and numbness for 2 weeks. She reported milder form of similar symptoms in past when she
was investigated with MRI brain was treated for MS. Physical examination revealed intact cranial nerves,
markedly decreased strength, decreased sensation and hyper reflexes in lower extremities. Her initial
labs were in normal limits. She was started on high dose of corticosteroids for possible MS. MRI brain
revealed extensive diffuse grey-white matter lesions and swelling of the optic nerves suggestive of prior
optic neuritis. CSF showed lymphocytic predominant high WBC count, high Glucose and normal protein.
Cytology did not show any malignant cells. Bacterial antigens were not detected and cultures were
negative. CSF IgG to albumin ratio, IgG index, IgG, IgM, and IgA levels were normal and there were no
oligoclonal bands; myelin basic protein and IgG synthesis rate were high; VDRL and Lyme titers were
negative. ESR and CRP were high but ANA, Anti DNA, SS-A, SS-B and Rheumatoid factor antibodies were
negative. MRI C-spine showed increased T2-weighted signal from the C3 level to the T5 level, signal
abnormality involved the central aspect of the spinal cord. MRI T-spine showed enhancing lesion within
thoracic cord posterior to the T2 through T6 within the central aspect of the spinal cord. In light of
patient's poor response to IV steroid and lesions seen on MRI of the entire spine, a more likely diagnosis
was LETM. She received plasmapheresis and showed a marked improvement in symptoms.
DISCUSSION: Longitudinally Extensive Transverse Myelitis (LETM) is a rare form of NMO in which the
spinal cord is predominantly affected. NMO (anti- Aquaporin-4 channel) antibodies are specific for this
entity. We report a very rare case of seronegative form of LETM which initially presented with typical
MS looking brain lesions, and report successful treatment with plasmapharesis.
Conclusion: In older patients with relapsing neurological symptoms mimicking MS; Negative work-up for
MS, infectious and autoimmune disorders should trigger diagnosis of NMO. Presence of contiguous
hyperintense lesion on spinal cord imaging suggests LETM. Absence of NMOantibodies in presence of
clinical impression and radiological evidence doesn’t exclude LETM. These patients should be treated
with plasmapharesis and not with high dose IV steroids.
416

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jharendra P Rijal, MBBS
Toxic Epidermal Necrolysis: An Extremely Rare But Dreadful Adverse Effect of Trimethoprim-
Sulfamethoxazole
Jharendra P Rijal, MBBS Tiffany Pompa, MD, Venkat Raja Surya, MD, MPH, Ayesha S Siddiqui, MBBS,
Tarek Abdallah, MD, Vijaya Raj Bhatt, MBBS
CASE PRESENTATION: A 62-year-old woman presented to the emergency department with diffuse
erythematous rashes over her body following the second dose of oral trimethoprim-sulfamethoxazole
use prescribed for uncomplicated lower urinary tract infection. The lesion started as painful
erythematous macules, turned into blisters followed by diffuse exfoliation of skin involving bilateral
lower extremities, back, abdomen, and both forearms. Past medical history was significant for
hypertension, dyslipidemia, coronary artery disease and coronary artery bypass graft. Her daily
medications included simvastatin, clopidogrel, aspirin, lisinopril and metoprolol. Patient denied any
known allergy. Physical examination was remarkable for multiples areas of erythema, blisters and
extensive detachment of skin involving 45 % body surface area. Face and oral cavities were spared.
Nikolsky sign was positive. She was admitted to the burn unit, and managed with intravenous fluid and
extensive wound care. A punch biopsy of skin revealed full thickness epidermal necrosis with
subepidermal blister formation and the presence of perivesicular lymphocytes as well as dermal
inflammation. This was consistent with toxic epidermal necrolysis (TEN). Hospital course was
complicated by cellulitis of right leg due to Pseudomonas aeruginosa and central venous catheterrelated
sepsis due to Acinetobacter baumanni sensitive only to tobramycin, acute respiratory distress
syndrome, acute kidney injury, and diastolic congestive heart failure. Intensive medical management
including aggressive antibiotic use and meticulous wound care with frequent wound debridement led to
the resolution of these complications. The patient had remarkable regeneration of skin over subsequent
few weeks and she was discharged home after one month.
DISCUSSION: TEN is a rare adverse drug reaction with an incidence between 0.4 to 1.3 cases per million
each year but with a mortality rate as high as 40 %. It is thought to result from an autoimmune reaction
in skin leading to necrosis and separation of the epidermis. Denuded skin and damaged mucosa
predispose to infection which can lead to sepsis and respiratory distress, as in our case. TEN is
diagnosed clinically with prodrome of fever, malaise, and multitude of nonspecific symptoms followed
by maculopapular painful erythema, blisters and sloughing of epidermis and mucous membrane
involving greater than 30 % body surface. The diagnosis is further supported by the history of drug
exposure and the histological findings as described above. Trimethoprim-Sulfamethoxazole, an
extremely commonly used antimicrobial, has been rarely reported to cause TEN. Given the lifethreatening
nature of the disease, both physicians as well as patients should be aware of this rare
complication. Although rapid onset of dermatologic changes without prodromal symptoms over a day is
an extremely unusual presentation, as illustrated by this case, it’s a distinct possibility. Early recognition
of signs and symptoms of TEN and early drug discontinuation is essential and decreases mortality.
417

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Muniba Rizvi, MD
A 20-year-old man with recurrent hypokalemic periodic paralysis and delayed diagnosis
Muniba Rizvi, MD Vijaya Raj Bhatt, MBBS, Rajiv Bartaula, MBBS, Rajesh Shrestha, MBBS, Michael
Tadros, MD, Srujitha Murukutla, MBBS, Jeffrey Rothman, MD, FACP, FACE
INTRODUCTION:When patients present with episodic paralysis it is important to identify the
underlying cause. We report a case of periodic paralysis in a young man with recurrent episodes and a
delay in diagnosis.
CASE PRESENTATION: A 20-year-old Chinese man presented to the emergency department with a 3hour
history of progressive weakness of all extremities that began on awakening in the morning. The
patient gave a history of similar episodes of muscle weakness occurring after intake of carbohydrate-rich
food. There was a history of periodic muscle weakness in his paternal uncle and grandfather. The
patient’s prior paralytic attacks were therefore attributed to familial hypokalemic periodic paralysis
(HPP) and he was treated with oral potassium supplementation. In addition to generalized muscle
weakness, physical examination revealed tremor of outstretched hands and tachycardia. The thyroid
was not palpably enlarged. Laboratory tests included serum sodium of 138 mmol/l, potassium of 3.1
mmol/l, chloride of 103 mmol/l, bicarbonate of 30 mmol/l, calcium of 9.0 mg/dl, magnesium of 2.3
mg/dl, glucose of 104 mg/dl, creatine kinase of 186 IU/L, renin of 8.43 ng/ml, and aldosterone of 3
ng/dl. Serum TSH concentration was 0.06 µIU/ml, with free T4 concentration of 2.6 ng/dl. Complete
blood count, renal and liver function tests were all within normal limits. The patient improved after
replacement of potassium. Further questioning revealed a history of tremors, sweating, tremulousness
and 5-pound weight loss over the past 5 weeks as well as a history of hyperthyroidism in the patient’s
maternal grandmother. A diagnosis of thyrotoxic periodic paralysis (TPP) was established and the
patient was started on oral propranolol and methimazole. During the following 10 days, patient had two
further episodes of paralysis that responded to potassium supplementation. Further evaluation included
a 24-hour radioactive iodine uptake of 77% with diffuse thyroidal uptake on imaging consistent with
Graves’ disease. The patient was then treated with a therapeutic dose of 131 Iodine. Five months after
131I therapy, the patient is doing well.
DISCUSSION: This case illustrates the relative lack of awareness of TPP among physicians leading to a
delay in diagnosis, which is heightened because TPP is often the first manifestation of thyrotoxicosis.
Thyroid function tests should be performed in all cases of periodic paralysis. This has important
therapeutic implications: because the pathogenesis of the disorder involves redistribution of potassium
and not total body depletion, TPP requires cautious potassium supplementation since rebound
hyperkalemia may occur with recovery and aggressive potassium use. Propranolol can be used to
reverse muscle weakness and symptoms generally resolve completely with correction of underlying
thyrotoxicosis.
418

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nishtha Sareen, MD
Late Presentation Infective Endocarditis in a Patient with CardioSEAL PFO Closure Device
Nishtha Sareen, MD* Valentin Suma MD** Departments of Medicine* and Cardiology**; Hofstra NSLIJ
School of Medicine, NY
INTRODUCTION: The presence of a patent foramen ovale (PFO) is prevalent within the population and
has been associated with increased risk for cryptogenic stroke. PFO closure devices (PFOCD) have been
increasingly used as an alternative to antithrombotic therapy for prevention of recurrent
thromboembolism. Procedural complications include malposition, embolization, fractures, hematoma,
residual shunting, and thrombosis. Infections are very rare and occur early postimplantation.
Endocarditis occurring more than 6 months postimplantation has never been reported. We present the
case of an infected CardioSEAL PFOCD occurring 5 years post-procedure.
CASE PRESENTATION: 59 year old male who presented to the hospital with transient left-sided
weakness 5 years postimplantation of a PFOCD. As part of his work-up, a transthoracic echocardiogram
(TTE) was performed which showed a mobile echodensity within the left atrium (LA). The
transesophageal echocardiogram (TEE) confirmed the TTE findings and revealed a large 2.2x0.6cm
mobile polypoid echodensity on the LA aspect of the PFOCD highly suggestive of thrombus or
vegetation. The patient reported no health problems (including fever), or any other invasive procedures
that would predispose him to developing endocarditis prior to presentation. He denied i.v. drug abuse.
In the absence of any signs of infection or fever a presumptive diagnosis of device thrombosis was made
and the patient was started on i.v. anticoagulation. However, given the size of the mass and potential
embolic risk, the decision was subsequently made to remove the mass surgically. Microbiological
analysis revealed the presence of MSSA and micrococcus species within the mass consistent with
vegetation. The patient had a stable post-operative course and was treated with six weeks of i.v.
antibiotics.
DISCUSSION: Few cases of infective endocarditis related to PFOCD have been reported in the
literature. All previous reports have involved infections occurring within 6 months of implantation,
before complete device endothelialization, as confirmed at the time of surgical removal. Uniquely, ours
is the first case of infection manifesting beyond this time period. During the first 3-6 months
postimplantation patients are at highest risk for complications, as the devices are not completely
endothelialized. Current guidelines recommend antibiotic and antiplatelet prophylaxis during this time
interval.
Our case highlights the importance of considering the presence of vegetation (or thrombus) associated
with a PFOCD in the differential diagnosis of a patient presenting with embolic phenomena or an
endocarditis-like picture even beyond the expected time frame, as prompt diagnosis and treatment are
crucial for preventing further catastrophic events and improving clinical outcome. As illustrated,
echocardiography plays a central diagnostic role in the management of these patients and should be
performed without delay.
419

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Gayathri Sathiyamoorthy,
MD
Bubbles In The Liver; Clostridium Perfringens Liver Abscess And Septicemia.
Gayathri Sathiyamoorthy MD., Shoma Singh MD., Patrick Kholitz MD., V Subbarao Boppana MBBS., Mitu
Maskey MD., Avrille George MD.,
INTRODUCTION: “This is a disease that begins where other diseases end, with death.” -NEJM
1979;301(23)
Liver abscess secondary to Clostridium perfringens is a rare phenomenon resulting in septicemia,
massive intravascular hemolysis and end organ damage. Due to its lack of recognition most cases thus
far have been fatal.
CASE PRESENTATION: A 65-year- old female with uncontrolled diabetes returns from a 2 month trip to
Jordan. She was doing well until the day prior to admission, when she suddenly developed high grade
fevers, chills, nausea and generalized weakness. The day of admission she developed right sided
shoulder and right upper quadrant abdominal pain. In the ER, her temperature was 39.1 degrees Celsius,
but otherwise was hemodynamically stable. She was diaphoretic and in significant distress. Her labs
were significant for elevated liver function tests, anemia, significant leukocytosis and acute kidney
injury. Imaging showed slightly thickened gallbladder wall and mildly dilated common bile ducts without
evidence of cholelithiasis, pericholecystic fluid or sonographic evidence of Murphy’s sign; however a
gas-containing hepatic lesion in the posterior aspect of the right hepatic lobe was noted on the CT scan.
Blood cultures drawn on admission formed gas, and grew gram positive rods, suggestive of clostridium
versus bacillius. Given these findings, the patient was immediately started on broad spectrum
antibiotics: Metronidazole was started to cover clostridium, its toxins and other anaerobes; Ampicillin
was started to cover Enterococcus and Listeria as well as other gram positive organisms; Ceftriaxone
was started to give broader gram negative coverage for the suspected intra-abdominal pathology. On
day two of her admission, the patients fever had subsided, and she felt subjectively better. However her
hemoglobin dropped further. Work-up indicated worsening hemolysis. On Gram’s staining, the organism
showed a double zone of hemolysis which helped further identify the organism as Clostridium
perfringens. Thus, she underwent an emergent interventional radiology-guided drain placement of her
hepatic lesion. Ten milliliters of pus was drained. She was also transfused with 2 units of blood. During
the subsequent days, her hemoglobin stabilized, acute kidney injury resolved and patients overall
condition improved significantly.
DISCUSSION: Thus far, approximately 42 cases of Clostridium perfringens septicemia have been
reported in literature. Of these 11 cases were due to liver abscess. Most cases were complicated by
severe hemolysis and multiorgan failure and many had fatal endings; especially when invasive
procedure to remove the focus of infection was not undertaken. This case demonstrates that with early
identification/recognition of this disease process and early intervention with drainage and antibiotics,
such complications can be eliminated.
420

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sunny Shah, MD
ST-segment Elevation Myocardial Infarction with In-stent Thrombosis Following DDAVP
Administration
Sunny Shah, Dept. of Medicine, NYULMC Henry Tran, Dept. of Medicine, Div. of Cardiology, NYULMC
Amer Assal, Dept. of Medicine, Memorial Sloan-Kettering Jeffrey S. Berger, Dept. of Medicine, Div. of
Cardiology and Hematology, NYULMC
INTRODUCTION: Desmopressin (DDAVP) has been shown to be both efficacious and safe when used to
treat patients with von Willebrand’s disease and hemophilia A, as well as to prevent blood loss in
patients undergoing cardiovascular surgery. In addition to these well studied situations, DDAVP is also
used to reverse the platelet dysfunction associated with uremia, cirrhosis, and anti-platelet agents such
as aspirin and clopidogrel.
CASE PRESENTATION: A 67-year-old man with a history of coronary artery disease was admitted to the
hospital after sustaining a traumatic injury to the skull. Three years prior, the patient underwent cardiac
catheterization which revealed severe stenosis of the proximal left anterior descending (LAD)
artery. This lesion was revascularized with angioplasty and placement of a drug-eluting stent. He was
subsequently treated with aspirin and clopidogrel. On the morning of admission, an air conditioner
spontaneously fell from a window, landed on an awning, and subsequently struck the patient on the
right side of the head as he was walking.
He was brought to the emergency room with a seven centimeter laceration on the right scalp. A noncontrast
CT scan of the head demonstrated a large subgaleal hematoma without intracranial
bleeding. Due to persistent bleeding, DDAVP was administered intravenously thirty minutes after
presentation. Five hours later, the patient complained of crushing chest pain. A 12-lead
electrocardiogram demonstrated 2 mm ST-segment elevations in the precordial leads with reciprocal
depressions in the inferior leads.
Emergent cardiac catheterization demonstrated total occlusion of the proximal LAD stent with TIMI 0
flow. Bivalirudin was initiated as per protocol. Atherectomy was attempted, but thrombus was not
aspirated. A Promus 3.0 x 18 mm stent was placed inside the original stent with restoration of TIMI 3
flow. During the catheterization, the patient became progressively hypoxic and hypotensive requiring
intubation, dopamine drip, and placement of an intra-aortic balloon pump (IABP).
The patient’s hospitalization was complicated by prolonged shock requiring inotropes and vasopressors.
The IABP was removed on day four. Dopamine was titrated off by day seven, and the patient
was successfully extubated on day 13. A transthoracic echocardiogram demonstrated a left ventricular
ejection fraction of 30% with severe anterior and apical hypokinesis. The patient was discharged to
inpatient rehabilitation on day 21.
DISCUSSION: This is the first reported case of an ST-elevation MI due to in-stent thrombosis occurring
after DDAVP administration. Though DDAVP is safe and efficacious in treating several types of
coagulopathies, this case illustrates its potential pro-thrombotic effects. Therefore, DDAVP should be
used with caution in patients with known coronary artery disease and coronary stents.
421

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Tulsi Sharma, MBBS
Pneumocephalus after attempted Epidural Anesthesia
Tulsi Sharma, MBBS Pankaj Mehta MD
INTRODUCTION:Epidural anesthesia and analgesia are being increasingly used as they facilitate an
earlier recovery and reduce the incidence of postoperative thromboembolic, pulmonary, and
gastrointestinal complications after major surgery.
CASE PRESENTATION: We present the case of a 66-year-old male with a history of perforated
diverticulitis and prior Hartmann pouch procedure, admitted for an elective colostomy closure. Epidural
catheter placement was initially attempted but was unsuccessful and the surgery performed under
general anesthesia. He underwent a colonoscopy and successful reversal of his colostomy. The patient
was successfully extubated and transferred to the postoperative recovery unit. His vitals were stable and
he was responding to commands. About 10 minutes after transfer the patient suddenly became
unconscious, hypoxic, with a strong neutral gaze nystagmus and his systolic blood pressure was over
200. He was reintubated and an emergent CT-head was done with concerns for a stroke. CT however
showed evidence of air in the ventricles. Where did the air come from? He had developed a
pneumocephalus from the attempted epidural anesthesia. He was transferred to the ICU and started on
100%FiO2. His sensorium and motor functions improved over the next few hours. Brain imaging over
the next 2 days revealed decreasing intraventricular air. He recovered without any neurological deficits
and was successfully extubated and transferred to the surgical service for his postoperative
management.
DISCUSSION: Pneumocephalus is a well-known complication of spinal anesthesia, but it is extremely
rare after an epidural puncture. We present this case to highlight the importance of a clinical suspicion
of this complication from epidural procedures. The differential of an acute onset headache after an
epidural puncture could be a postdural puncture headache(PDPH), a subarachnoid hemorrhage(SAH), or
a pneumocephalus. Patients present with signs of frank neurological injury as in our patient, but some
may present with only subtle signs or with just a persistent severe headache. An important clue may be
that these headaches are typically not position dependent in contrast to the PDPH.
The postulated mechanism of air entry is either by injection during procedure when air is used in the
loss of resistance technique or by the pressure differential created between the spine and an
unoccluded needle. The potential for a pneumocephalus can be reduced by using normal saline during
the loss of resistance technique as well as limiting the time the stylet is withdrawn from the needle. Less
than 2ml of subarachnoid air can cause headache but the correlation between the amount of
intracranial air and headache symptoms is less than perfect.
The use of a high oxygen concentration can hasten absorption of intracranial air and reduce chances of
neurological injury. Prognosis is usually good and an early diagnosis may prevent unnecessary tests and
interventions.
422

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Tulsi Sharma, MBBS
An Unusual Cause of Multiple Pulmonary Nodules
Tulsi Sharma, MBBS Pankaj Mehta, MD Roberto Izquierdo, MD
INTRODUCTION: Many diseases can present with a miliary lung pattern, especially in
immunocompromised patients. What can be the differential in a young asymptomatic and
immunocompetent individual?
CASE PRESENTATION: We present the case of a 21-year-old lady who had been in her usual state of
health until October 2008 when she had a motor vehicle accident. A CT-thorax obtained at an outside
facility did not reveal any traumatic injury, however, it revealed a diffuse reticulonodular pulmonary
process. Subsequent sputum for AFB and PPD were negative and she was asymptomatic. She did not
return for her follow-up appointments and returned to her PCP in November 2009 for a regular yearly
evaluation. Repeat CT-thorax revealed a stable nodular pattern. She was then referred to Upstate
Medical University with possible diagnosis of sarcoidosis. At the time of referral in early 2010 she still
denied any constitutional symptoms. Clinical exam was normal. Repeat CT-thorax revealed persistence
of the miliary pattern. Blood work, ACE-level and PPD were negative. What would cause these numerous
nodules which have been stable for 2 years and without any clinical manifestations?
After discussion of the risks and benefits of bronchoscopy, the patient agreed to the procedure.
Bronchoscopy with transbronchial biopsy revealed metastatic well-differentiated papillary thyroid
carcinoma (PTC)! Sonography of the thyroid revealed a small solid nodule in the left thyroid lobe with
internal and peripheral vascular flow on Doppler interrogation of the nodule. The patient underwent a
near-total thyroidectomy and a limited central compartment neck dissection. The patient has since
undergone radioactive iodine therapy and is on thyroid hormone replacement therapy. Her follow up
hypothyroid I131 whole body scan showed a significant decrease in uptake in the lungs.
DISCUSSION: Papillary thyroid carcinoma is the most common malignant thyroid cancer, and accounts
for approximately 80% of thyroid cancers. Involvement of regional lymph nodes is seen in 20-80% of
patients with PTC at the time of initial surgery. Diffuse lung metastatic disease from an occult thyroid
cancer is however extremely rare. Diagnosis based on a transbronchial biopsy in an asymptomatic
patient with incidental nodules makes it even more intriguing.
The growth rate of pulmonary nodules is often used to help differentiate benign from malignant disease.
Pulmonary nodules that exhibit lack of growth for more than two years are generally considered benign.
However, nodular lung metastases from papillary thyroid carcinoma are an exception and may
demonstrate lack of significant growth over years. The cause of this arrest of metastatic growth in PTC is
unknown.
PTC has the best prognosis of the thyroid malignancies with a 90% 10-year survival. Even in the presence
of metastatic spread, survival periods may exceed 20 years, especially in the young. Hopefully the
accident was actually a blessing in disguise!
423

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Yahuza Siba, MD
Not All That Is White Is Candida: A Case Of Recurrent Aspergillus Esophagitis In An Hiv/Aids Patient.
Yahuza Siba, MD
INTRODUCTION: The differential diagnosis for odynophagia/dysphagia in an AIDS patient is broad, thus
tissue diagnosis prior to treatment is very important to avoid misdiagnosis.
CASE PRESENTATION: A 23 year old Hispanic woman (homosexual orientation) with perinatally
acquired HIV, non compliant with antiretroviral (ARV) therapy with recent CD4 count of 11 and viral load
of 187, 000 presented with severe odynophagia. She has history of opportunistic infections including
oral candidiasis, pneumocystic jeroveci pneumonia and anal warts. She was referred from the infectious
disease clinic for parenteral therapy with caspofungin for oral candidiasis as patient did not get
symptomtic relief with nystatin and prior therapy with fluconazole for oral candidiasis was discontinued
because of erythema multiforme.
Vitals at presentation were: Temperature 99.4F, Pulse 111, BP 119/75 her body mass index was 23.9.
Physical exam was notable for florid oral thrush. The remainder of the exam was unremarkable. She
was admitted with the impression of oral/esophageal candidiasis and was started on caspofungin. She
underwent EGD which showed copious whitish patch involving the proximal and mid-esophagus
consistent with candida. Preliminary histology showed acute necrotizing candidiasis, pending special
stains. Aspergillus (probably fumigatus) was the final diagnosis after GMS stain. Patient’s antifungal was
switched to Amphoterin B (lipid form), her dysphagia resolved and was discharged for outpatient follow
up. A second EGD done one month later showed whitish lesions had cleared with negative biopsy
results. Four months later she again presented with odynophagia and repeat EGD with histology
histology showed Aspergillus spp. Meanwhile patient has refused re-treatment and her follow up visit is
pending.
DISCUSSION: Aspergillus spp. are ubiquitous in nature and grow in a variety of conditions. The septate
hyphae are characteristically 3-6um in diameter and branch at 45% angles. The most critical
determinant for inhalation of Aspergillus conidia progressing to invasive disease is the status of the host
defenses. Risk factors for invasive aspergillosis include neutropenia, aplastic anemia, high dose
corticosteroids, advanced HIV/AIDS, poorly controlled diabetes mellitus, post chemotherapy and after
bone marrow transplantation.
Our patient had an an advanced AIDS with very low CD4 count and high viral load. Aspergillus
esophagitis is one of the uncommon gastrointestinal manifestations of HIV/AIDS, our patient had what
both clinically and endoscopically appeared to be candida and initial histopathology report was also
reported as candida, however after special fungal staining it turned out to be Aspergillus which
ultimately changed therapy. This case demonstrates the importance of endoscopic biopsy in
immunocompromised patients presenting with dysphagia.
424

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Hemant Sindhu, MD
RSV Infection-Induced ARDS in a Young Immuncompetent Woman
Hemant Sindhu
INTRODUCTION:Respiratory syncytial virus (RSV) is the most important cause of lower respiratory tract
infections in young children. Despite being primarily known as a pediatric pathogen, RSV is now
recognized as a significant problem in adult populations as well. Most illnesses are mild in adults, but
significant morbidity and mortality can develop. We present the case of an adult female with RSV
infection-induced adult respiratory distress syndrome.
CASE PRESENTATION: A 41 y.o. female with past medical history significant for breast cancer was
admitted with a five day history of progressive shortness of breath, non-productive cough, chest pain,
fever and chills. The patient was a teacher’s aide at an elementary school and had been evaluated in the
emergency department two days prior to admission with similar symptoms and discharged on
azithromycin. Less than 24 hours after admission the patient developed acute respiratory failure
requiring intubation and was transferred to the medical intensive care unit. Vitals on admission were
remarkable for a temperature of 104.7°F and HR of 115 bpm. The physical exam was unremarkable
except for sinus tachycardia. The laboratory analysis showed a leukocyte count of 6700/mm3, with 91%
neutrophils, 7% bands, and 7% lymphocytes. Sputum gram staining revealed no bacterial or fungal
pathogens. The initial chest radiograph (CXR) was clear with no evidence of acute disease. The CXR post
intubation revealed diffuse bilateral alveolar infiltrates consistent with adult respiratory distress
syndrome (ARDS). Urine antigen for legionella, particle agglutination test for the antibody for
Mycoplasma pneumonia and nasopharyngeal swab for influenza were all negative. The patient
underwent fiberoptic bronchoscopy and staining for bacteria, fungi, tuberculosis, as well as sputum and
bronchoalveolar lavage liquid cultures all came back negative as well. However EIA for the RSV antigen
in BAL liquid was intensely positive. Prior to the diagnosis of RSV, this patient had been treated with
broad spectrum antibiotics but no improvement was observed clinically since the patient was still
requiring mechanical ventilation and had persistent lung infiltrates on CXR. Thus, the administration of
inhaled ribavirin was considered, however before the medication could be given to the patient, she
expired.
DISCUSSION: The overall mortality of RSV infection-induced ARDS in previously healthy adults is 40%-
60%. Diagnosis of RSV infection in adults is difficult because viral culture and antigen detection are
insensitive tests due to low viral shedding. The treatment guidelines currently in existence for RSV in
adults continue to be limited. Ribavirin is the only anti-viral agent approved for the treatment of RSV in
the pediatric population. A few case reports have been published in which adult patients have been
successfully treated with inhaled ribavirin. The role of inhaled ribavirin in adults is controversial, but it
might have a therapeutic potential for severe RSV infection-induced ARDS in adults.
425

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Deepthi Sara Sony, MD
Hypercalcemia and Tuberculosis : Common Bed fellows.
Deepthi Sara Sony, MD Second Author: Steven Colby, MD. New York Methodist Hospital, 506, 6th
Street, Brooklyn-11215.
INTRODUCTION: Many granulomatous diseases, including pulmonary and extra-pulmonary
tuberculosis (TB) have been associated with hypercalcemia. Serum calcium levels up to 15 mg/dl have
been reported in tuberculosis with hypercalciuria and normal-to-low parathyroid hormone (PTH) levels .
CASE PRESENTATION: A 66 yr old Ukrainian man with a 3-year history of diabetes mellitus type 2
presented with symptoms of urinary tract infection for which he received intravenous antibiotics. After
a few months he saw his doctor for weakness, fatigue and 6-pound weight loss. He had evidence of
acute renal failure with creatinine of 2.3 mg.dl (normal-1.2) and hypercalcemia (calcium 13.1 mg/dl;
normal,

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Yuzhu Tang, MD
A Case Of Miller Fisher Syndrome With Unusual Features: Brisk Tendon Reflexes And Facial Palsy
Yuzhu Tang, MD, Second author: Khadija A. Mamsa, MD, Asok K. Lahiri*, MD, Zev Carrey, MD, Richard L.
Petrillo, MD, Dariush Alaie, MD. Department of Medicine and Neurology*
INTRODUCTION:Miller-Fisher syndrome (MFS), a variant of Guillain-Barre syndrome, which was
described by Dr. Charles Miller Fisher, consists of the triad of ophthalmoplegia, areflexia, and ataxia in
its classical form. Here we report a case of MFS which showed in addition to classical features,
association of facial palsy and exaggerated reflexes, both of which are very rare in this condition.
CASE PRESENTATION: A 64-year-old male presented with one day history of headache, double vision
and wobbly gait. He had mild diarrhea and bronchitis 10 days ago for which he took doxycycline. He
gave no history of disturbance of consciousness. Physical examination was normal except for left 6th
cranial palsy and ataxia of gait. Pupils were equal and reactive to light. Patient managed to walk a few
steps with unsteady gait.
On following day, there was worsening of his condition. His vision was no longer double, rather blurred.
He was unable to walk due to ataxia. On examination, both eyes were fixed in forward gaze positions
with no ocular movement. Pupils were equal, but reaction to light was sluggish compared to previous
day. Deep tendon reflexes were brisk. Over the next few days, he developed right facial muscle
weakness, and deep tendom reflexes remained brisk. Ophthalmological consultant confirmed external
and internal ophthalmoplegia. CT and MRI head showed no focal structural brain lesion, only
periventricular microvascular ischemia. Laboratory findings showed normal glucose level, HbA1c 6.2%,
negative RPR, normal lyme titer. Tensilon test was normal. CSF analysis protein was 39.44 mg/dl,
Glucose 64 mg/dl, Cells 0, and negative culture.
Diagnosis of MFS was suspected on clinical basis and subsequently confirmed by elevated serum antiganglioside-GQ1b
level 43.
The patient was treated with IVIG for 5 days. He showed mild improvement in headache and facial palsy,
and could walk unsteadily prior to discharge to short term rehabilitation center. Total ophthalmoplegia
persisted.
DISCUSSION: Since MFS is a rare condition, common etiologies of acute onset of ophthalmoplegia and
ataxia, such as brainstem stroke, infection, diabetic cranial neuropathy, Wernicke’s encelopathy and
ocular myasthenia etc should be ruled out before the diagnosis of MFS. Despite the brisk reflexes,
Bickerstaff brainstem encephalitis is unlikely in this case because of the normal CSF study and no
disturbance of consciousness.
Ophthalmoplegia is the most prevalent symptom in MFS which is closely correlated with anti-GQ1b IgG
antibody, whereas facial palsy is only seen in about 22% of patients. Brisk tendon reflexes are seldom
seen in MFS.
427

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Pallawi Torka, MD
Flatbush Diabetes: Freedom from Needles
Pallawi Torka, MD Co-author: Debra Buchan, MD
INTRODUCTION: Flatbush Diabetes is atypical, ketosis prone diabetes mellitus (DM) that presents with
ketoacidosis. However, in contrast to type 1 DM, patients with Flatbush diabetes undergo spontaneous
remission and maintain long-term insulin independence. This clinical vignette highlights the evolution
and clinical aspects of Flatbush diabetes.
CASE PRESENTATION: A 45 year old previously healthy African lady, originally from Tanzania,
presented in diabetic ketoacidosis (DKA). She had no prior personal or family history of diabetes. Her
BMI was 26 kg/m 2 . DKA was corrected and the patient was discharged on insulin. However within a
month, her insulin requirements dropped drastically and she started becoming hypoglycemic. Insulin
was stopped. She was able to control her sugars through diet; HbA1C was 6.2% three months later. The
patient presented again eight months after initial symptoms with fatigue, weight loss and vaginal
candidiasis. This time HbA1C was 9.2%. Fingerstick glucose was 378 mg/dl; however, anion gap was
normal and there were no ketones in the blood or urine. She was restarted on insulin. Test results for
anti glutamic acid decarboxylase and anti islet cell antibodies were negative; metformin was introduced
in addition to insulin. Her insulin requirements have decreased since; however, it remains to be seen if
she will be able to come off insulin.
DISCUSSION: Flatbush or Ketosis prone Type 2 diabetes was initially described in African Americans but
subsequently, it has been reported in other ethnicities too, especially South Asians. The mean age of
presentation is 40 years, with 2- to 3-fold higher preponderance in men. The prevalence of obesity is
high among these patients and more than 80% have a family history of Type 2 DM. Typically, these
patients present with unprovoked DKA in association with polyuria, polydipsia, and weight loss for less
than 6 weeks. Although most patients undergo spontaneous remission requiring discontinuation of
insulin therapy within a few weeks, an estimated 60% to 70% of patients relapse within two years and
require either oral hypoglycemic agents or insulin. Physicians need to be aware of this unusual form of
DM and be able to differentiate it from either slowly progressive Type 1 DM or the “honeymoon phase”
of Type 1 DM; the differences between the two are summarized in the table below.
Population
Age group
DKA
Insulin
Oral hypoglycemics
Autoimmune markers
428
Flatbush diabetes Type 1 DM
African-Americans
Middle-age
Usually doesnot recur
Transient requirement
Mainstay
Absent
No predilection
Younger
Prone to recurrences
1 st line treatment
No role
Present

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nay Min Tun, MD
Delayed Epiphyseal Closure in a Patient with Sickle Cell Anemia Complicated by Primary
Hypogonadism
Nay Min Tun, MD Second Authors: Linus Yoe, MD; Kathy Khaing, MD; Ma Sandar, MD; Aye Min Soe, MD
INTRODUCTION:Hemoglobin S is most prevalent in tropical Africa. Sickle cell trait has a frequency of
approximately 8 percent in African-American populations. The expected prevalence of sickle cell
anemia in the United States is 1 in 625 persons at birth. Impairment of skeletal and sexual maturation in
early adolescence in patients with sickle cell anemia has been recognized. Plausible mechanisms include
hypopituitarism resulting from intravascular thrombosis and pituitary infarction, reduced
responsiveness of the testes to pituitary LH and FSH, and zinc deficiency.
CASE PRESENTATION: 21-year-old African American male presented with low back, chest and bilateral
knee pain. His past medical history was significant for sickle cell anemia with 4-5 pain crises a year and
laparoscopic cholecystectomy. He had strong family history of sickle cell anemia and trait. Physical
examination disclosed eunuchoidal skeletal proportions with a height of six feet and six inches and
underdevelopment of secondary sexual characteristics. His pain symptoms improved with hydration and
analgesia although the right knee pain persisted. X-ray of the right knee joint showed moderate
suprapatellar joint effusion, 1.2 x 0.5 cm ovoid radiolucency in the femoral intercondylar notch and nonclosure
of the epiphyseal plate. Magnetic resonance imaging revealed acute distal femoral metaphyseal
marrow infarct, non-closure of epiphysis with a small region of non-specific edema, and moderate joint
effusion. Bone age assessment with X-ray of the hand showed a physiological bone age of 18 years and 0
months (+/- 10 months). Hormonal workup was done to find out the cause for delayed skeletal growth.
He was found to have low total and free testosterone levels with high follicular stimulating hormone
(FSH) and luteinizing hormone (LH) levels. Prolactin level was mildly elevated that might be attributable
to hydromorphone that was given for pain. Thyroid function and Cosyntropin stimulation tests were
normal so were random cortisol, growth hormone and insulin-like growth factor 1 levels. He was
diagnosed to have primary hypogonadism, and testosterone therapy and multivitamin supplementation
were initiated with subsequent improvement in libido and virilization.
DISCUSSION: Delayed epiphyseal closure in our patient was presumed to be due to testicular androgen
deficiency. In our patient, relative rather than absolute androgen deficiency seemed to exist,
probably arising from diminished sensitivity of the testes to pituitary LH and FSH. There were several
studies reporting sickle cell anemia in association with primary or secondary hypogonadism and zinc
deficiency. Physicians should be aware of hypogonadism as a possible complication of sickle cell anemia
in a young patient, its possible causes, and the importance of appropriate and timely treatment.
429

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jose A Villamil, MD
Recurrent Early Stent Thrombosis Associated with Clopidogrel and Prasugrel Resistance: A Case
Report
Jose A Villamil, MD, Arismendy Nunez, MD, Motaz Moussa, MD, George Fernaine, MD, FACC
INTRODUCTION: Platelet inhibition using a combination of aspirin and thienopyridines is the standard
therapy to prevent stent thrombosis after percutaneus coronary intervention (PCI). The etiology of stent
thrombosis is multifactorial; however it occurs more commonly in individuals with resistance to
clopidogrel. Clopidogrel resistance has been associated to genetic variability on the CYP 2C19 enzyme
which metabolizes the drug into its active form. Newer third generation thienopyridine prasugrel is a
more potent antagonist of P2Y12 receptor. Its antiplatelet activity is claimed to be independent of
genetic polymorphism of CYP2C19; therefore prasugrel is used as the alternative to manage cases of
clopidogrel resistance. We present a case of recurrent acute STEMI due to early thrombosis after PCI,
indicating clinical resistance to both clopidogrel and prasugrel.
CASE PRESENTATION: A 71-year-old Caucasian woman with CAD presented to the ED complaining of
typical chest pain. Initial EKG showed sinus rhythm and old inferior wall MI. The patient was initially
started on aspirin and clopidogrel (loading dose of 600mg) and admitted to the cardiac care unit (CCU).
Later she underwent cardiac catheterization with placement of four drug eluting stents, two in left
anterior descending artery (LAD) and two in diagonal artery (D1). Post PCI she continued taking
clopidogrel and aspirin. Two days later, chest pain recurred, and EKG revealed acute anterior wall STEMI
ST. Emergent angiogram showed 100% occlusion of LAD and diagonal stents. Successful
revascularization of LAD was achieved, and a blood sample was taken for genetic testing (CYP2C19
variant). Patient was transferred to back to the CCU and started on prasugrel for suspected clopidogrel
resistance. Three days later she developed chest pain and EKG showed acute anterior wall STEMI.
Repeated angiogram showed 100% occlusion of the LAD, after successful thrombectomy and
angioplasty of LAD, patient underwent emergent coronary artery bypass surgery for suspected prasugrel
resistance. Genetic testing showed one copy of CYP2C19*2 variant. This mutation is associated with
decreased activity of CYP2c19.
DISCUSSION: Thienopyridine resistance may lead to life threatening complications such as
early stent thrombosis. In vitro studies have shown that resistance to prasugrel and clopidogrel occurs in
6% and 45 % of patients respectively; however, not all cases of laboratory resistance are accompanied
by clinical resistance. In the setting of post PCI chest pain, stent thrombosis and thienopyridine
resistance should be suspected. It is important to recognize that resistance to thienopyridines occurs for
both clopidogrel and prasrugel. Further research is needed to identify prasugrel resistance as well as
the subset of patients who may be resistant to the thienopyridine class.
430

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Mehran Yaghmaie
Life Threatening Unilateral Emphysematous Pyelonephritis, Managed By Medical Therapy Alone
Mehran Yaghmaie Jehanzeb Khan MD, Karen Beekman MD, Hita Sharma MD, Sam Nia MD
INTRODUCTION: Introduction
Emphysematous pyelonephritis (EPN) is a rare necrotizing infection of renal parenchyma characterized
by the production of gas in the intra and perirenal tissues. Diabetic patients account for 70–90% of all
cases. The infection often has a fulminating course with mortality up to 50%. It is believed that high
levels of glucose in association with inadequate perfusion, lead to a favorable environment for the
growth of anaerobic organisms within the kidneys. Other conditions involved in the pathogenesis of EPN
include urinary tract obstruction, partially treated sepsis, lymphatic obstruction, lipid metabolism
abnormalities and impaired immune responsiveness. Diabetic microangiopathy by causing slow
transport of catabolic products can lead to gas accumulation. Among causative organisms, Escherichia
coli is isolated in 66% cases. Klebsiella, Proteus, Pseudomonas, rarely Clostridium and Candida
species have also been isolated. Patients typically present with fever, abdominal or flank pain, nausea
and vomiting, dyspnea, acute kidney injury, altered sensorium, shock and thrombocytopenia. Crepitus
over the flanks may occur in advanced cases. CT scan is the best tool for diagnosis.
Case presentation
A 62 years old female presented with history of left lower quadrant abdominal pain for four days.
Patient had poorly controlled diabetes mellitus(HbA1C 12).Patient described her abdominal pain as
gradually worsening, non-radiating, associated with nausea, and vomiting. Patient also complained of
subjective fever with chills. Physical examination revealed marked left sided CVA tenderness with
guarding. CT scan of the abdomen showed the presence of air in left renal collecting system, renal pelvis
and the anterior aspect of the urinary bladder. There was heterogeneous enhancement of both kidneys,
more prominent on the left, highly suspicious for pyelonephritis. Laboratory results significant for
marked leukocytosis (19,000) and hyperglycemia (550 mg/dl). Patient was promptly started on IV
ciprofloxacin, clindamycin and gentamicin were promptly begun On day 3 urine culture grew E. Coli and
antibiotics changed to ertapenem. Tight glycemic control was also achieved. A follow-up CT abdomen
obtained after four days showed global improvement of pyelonephritis with absence of gas. Because of
adequate response to antibiotics, scheduled nephrectomy was canceled. Patient was discharged on oral
antibiotics.
Discussion
Our patient is among the very few reported cases of emphysematous pyelonephritis managed by
medical therapy alone. Although the gold-standard therapy for EPN is considered to be nephrectomy,
conservative treatment with antibiotics should be considered first. If the patient has significant exudate
along with gas in the renal parenchyma and perinephric tissues, initial percutaneous drainage should be
performed. A recent review Aswathaman et al (2008) , reported that 80% of EPN patients were
successfully treated with early initiation of percutaneous drainage and antibiotics alone without
requiring nephrectomy.
431

NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jun Zhang, MD PhD
CIDP Masquerading as Metabolic Polyneuropathy
Jun Zhang, MD, PhD; Other coauthors: Zinah Abdulqader, MD; Dimitry Olivier, MD; Jean Francois, MD;
Sonia Borra, MD
INTRODUCTION:CIDP (Chronic inflammatory demyelinating polyneuropathy) is a chronic neuropathy of
supposed immune-mediated origin. It is thought to be a common but underdiagnosed disease because
the differentiation can be sometimes very challenging, especially when a metabolic polyneuropathy
could be a plausible explanation for neurological manifestations under conditions such as diabetes and
uremia. Early recognition of CIDP is thus crucial as it is a potentially treatable disease.
CASE PRESENTATION: A 61-year-old African American man with long history of diabetes and
hypertension as well as end stage renal disease presented with progressive weakness of both legs for 3
months. It started as difficulty walking while carrying weights then to inability to move completely,
associated with burning sensation over his bilateral foot soles. "Diabetic polyneuropathy" was initially
proposed, but a diagnosis of "uremic polyneuropathy" was made after his condition worsened along
with deteriorating kidney function. He started hemodialysis about 2 months ago but no obvious
improvement was observed even with more frequent daily dialysis. On presentation, patient was obese
with BMI of 45.7kg/m2, temperature 98F, heart rate 65/min, respiration rate 16/min and BP 174/67.
Physical exam revealed normal mental status with normal cranial nerve function. There was mild
weakness over bilateral upper extremities (4/5 in strength) with thenar atrophy, and a complete loss of
muscle strength (0/5) over bilateral lower extremities, which were swelling up to the thigh. No
spasticity, rigidity, tremor or fasciculations were observed. The light touch, pain, vibration and
temperature sensations were grossly intact except abnormal pain elicited by fine touch in the soles of
both feet. The sense of position was severely impaired in the lower extremities. Notably, there was a
complete loss of deep tendon reflex in all extremities. MRI without gadolinium (due to renal function)
showed multiple degenerative spinal discs, but neither central canal compromise nor acute cerebral
events were observed. An electromyogram and nerve conducting study revealed findings suggestive of
primary demyelinating polyneuropathy with some axonal lesions. A subsequent cerebrospinal fluid
analysis showed elevated protein level (85.9 mg/dl, normal: 15-45 mg/dl) with zero leukocyte count.
Despite his refusal of nerve biopsy, the existence of CIDP possibly on the top of diabetic or uremic
polyneuropathy was thus proposed, and treatment with prednisone and intravenous immunoglobulin
started. After 3 days, patient began to feel stronger subjectively, and after 5 days, he was able to move
his toes. However, presumably due to preexisting axonal damage from either diabetes or uremia, and
also a relatively delayed recognition of CIDP, his recovery was not complete.
DISCUSSION: This case illustrated the challenge and importance of recognizing CIDP in patients with
systemic diseases of metabolic origin such as diabetes, uremia, etc. Although metabolic dysregulation in
those conditions is frequently associated with neuromuscular complications, CIDP still deserves to be
part of the differential if a patient presents mainly symmetric motor polyneuropathy for more than 8
weeks and symptoms cannot be fully explained by metabolic polyneuropathy. A diagnostic workout and
subsequent treatment should be initiated as soon as possible to maximize the chance of therapeutic
success.
432

NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Heather B
Friedman, MD
"What the Heck, I Can’t Move My Neck!"
Heather B Friedman, M.D., Toni Evans, M.D., Beth Susi, M.D.
INTRODUCTION: CASE PRESENTATION: A 30-year-old African American male presented to the
Emergency Department with the chief complaint “I can’t move my neck.” He had experienced 1 year of
progressive neck and back pain, as well as stiffness which was worse when he sat down and better while
walking. His past medical history included a bilateral leg deformity since childhood with corrective
surgery and iron deficiency anemia. Review of systems was notable for a 200 pound unintentional
weight loss over the past year, and extreme weakness, in addition to the inability to move his head. He
had no fevers, rashes, eye complaints, other joint pains, or gastrointestinal changes. He took no
prescribed nor over the counter medications. Physical exam revealed a chronically ill-appearing man
who had clear immobility of his C-spine. His Schober’s test revealed lumbar flexion of only
2cm. Multiple superficial skin erosions were present along his spine and his lower extremities had postsurgical
scars. His abdominal exam was unremarkable but his stool was hemoccult positive. Initial labs
demonstrated a microcytic anemia with an MCV of 69 and Hgb of 7.8, platelets 552, albumin 2.7, CRP
11.9, ESR 109.
A CT of his spine showed findings of a diffuse ankylosing process of the cervical spine and upper thoracic
spine which was highly suggestive of Ankylosing Spondylitis. There was fusion at the craniocervical
junction and markedly irregular C1-C2 articulations. An HLA-B27 was negative, and MRI of his entire
spine showed diffuse facet fusion. He also received packed RBC’s and underwent a colonoscopy, which
demonstrated severe inflammation and serpentine ulcerations found in a continuous and
circumferential pattern from the terminal ileum to sigmoid colon, sparing the rectum. The terminal
ileum was severely erythematous and ulcerated; pathology was consistent with Crohn's Disease.
DISCUSSION: The Spondyloarthropathy Disorders are a heterogeneous group of arthritidies commonly
associated with Inflammatory Bowel Disease. This case is particularly unusual in that our patient’s initial
presentation of his Crohn’s Disease was a fused cervical spine. Typically with spondyloarthropathy,
especially Ankylosing Spondylitis, patients experience increasing low back pain with sacroiliac joint
involvement and the disease progresses cranially. Of the various enteropathic spondyloarthropathy
disorders, only 60% are associated with HLA-B27 positivity, even fewer if African American in race;
hence our patient being negative for the marker is not atypical. For treatment of his newly diagnosed
Crohn’s, he was started on prednisone along with 6- Mercaptopurine. Given the fact that his spine is
largely fused at this point, treatment with a TNF inhibitor may not benefit his arthritic process, but may
aid in the treatment of his Crohn’s Disease.
433

NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Suheir Khajuria,
MD
EGFR mutation in advanced NSCLC
Suheir Khajuria, MD, MPH Second Author: Andrew Schreiber, MD
INTRODUCTION:Non-small cell lung cancer (NSCLC) with brain metastasis is associated with poor
prognosis and a median survival of less than one year. Platinum based doublet chemotherapy remains
the treatment of choice for the majority of patients. NSCLC patients with certain Epidermal Growth
Factor Receptor (EGFR) mutations have shown to benefit from EGFR tyrosine kinase inhibitors.
CASE PRESENTATION: A 60 year old Caucasian female presented with headache, progressive slurring
of speech and tingling sensation in her left leg. She had a 60-pack year smoking history and no focal
deficits on examination. CT head revealed numerous masses throughout cerebral hemispheres
consistent with metastatic disease. CT of her chest/abdomen revealed an irregular 2.4 X 2.8 cm left
lower lobe lung mass along with a 6.3 cm right hepatic lobe mass. She received whole brain irradiation
initially secondary to her CNS symptoms. Lung biopsy was consistent with adenocarcinoma and liver
biopsy confirmed metastatic disease. She was Cytokeratin 7 positive, Cytokeratin 20 negative, Thyroid
transcription factor-1 positive, suggesting a lung primary (stage IV). Her ECOG performance status was 1.
After palliative chemotherapy was started with Carboplatin and Alimta, she was found to be positive for
EGFR mutation for exon 18. Her imaging studies on Carboplatin/Alimta showed no improvement in her
widely metastatic disease. She was switched to oral Tarceva after 3 cycles of Carboplatin/Alimta. Her
symptoms of fatigue, weakness, and nausea showed significant improvement with treatment side
effects of only a mild acneiform rash on her face and mild diarrhea. After 6 weeks of Tarceva, imaging
studies revealed reduction in size of the lung mass and hepatic lesion. She resumed work and was
continued on Tarceva.
DISCUSSION: Approximately 15% of the U.S. population with advanced NSCLC is found to have EGFR
mutations within the tyrosine kinase domain. These are more commonly seen in Asian, non-smoker
females and occur within EGFR exons 18-21. Over 90% of mutations occur within exon 19 and 21.
Erlotinib (EGFR tyrosine kinase inhibitor) has shown improved survival as a first line therapy in chemonaive
patients having NSCLC with brain metastasis. In this case, patient was positive for exon 18 EGFR
mutation and had already received standard chemotherapy prior to Erlotinib without a clinical
response. Treatment with Erlotinib showed regression of disease and improved quality of life. Studies
have also supported that development of rash as in this patient is consistent with the likelihood of
clinical benefit from Erlotinib. Thus, all stage IV lung Adenocarcinoma patients presenting with brain
metastasis should be tested for EGFR mutations. Trials assessing the role of EGFR inhibitors as a single
agent and in combination therapy for such patients are in progress.
434

NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Ross M Nesbit, MD
Get the Lead Out: An Unusual Case of Cryptococcal Endocarditis
Ross M Nesbit, MD Beth Susi, MD FACP James Horton, MD David Weinrib, MD
INTRODUCTION: A 55yo African American male presented with worsening fatigue and
“sluggishness”. He had felt well until 2-3 months prior, when he developed progressive fatigue, fevers,
chills and a 20 pound weight loss. PMH included prophylactic automatic implantable cardioverterdefibrillator
[AICD] placement in February 2010 for non-ischemic cardiomyopathy, as well as
hypertension and diabetes. Review of systems was unremarkable; he denied palpitations or the
sensation of his AICD firing.
CASE PRESENTATION: Physical exam showed low grade fever and an initial BP 88/53 and HR 112,
both of which corrected with fluid resuscitation. Blood cultures were obtained which were positive for
yeast on day 3 of incubation. This prompted an HIV antibody test and confirmatory Western blot; both
returned positive. Initial transthoracic echocardiography revealed an EF of 35% and moderate mitral
regurgitation; subsequent transesophageal echocardiography showed a mitral valve vegetation with
stranding and a mobile mass on the apical portion of the right ventricular [RV] AICD lead. Additionally,
the blood culture growth was definitively identified as Cryptococcus neoformans. At the time of the
AICD removal, the RV ICD lead was noted to be covered in a thin, white film. Treatment with
amphotericin and 5-flucytosine was initiated, and after the removal of the device there were no
additional positive blood cultures, including fungal cultures.
DISCUSSION: There is a dearth of information regarding Cryptococcal endocarditis, with only five
reported cases thus far in the literature, and no cases involving a pacemaker or AICD. Available data for
infection following ICD or pacemaker implantation puts the risk of infection between 0.8 and 5.7%,
depending on the implanting physician’s procedural volume. More recent data reveals a device-related
infection rate of less than 1% for initial device implantations. True device endocarditis is even less
common, with recent literature showing an incidence of 0.5% of all device insertions. The
immunocompromised patient presents a greater treatment challenge, especially in the case of
cryptococcal organ involvement. Our treatment was like that of cryptococcal meningitis, using induction
therapy with intravenous liposomal amphotericin and 5-flucytosine, followed by maintenance therapy
with fluconazole. Removal of the device was critical, as its presence would serve as a continued nidus
for infection. Fortunately, device interrogation revealed no prior ventricular arrhythmias, and thus the
ICD was able to be removed. As new data emerges supporting the use of implantable defibrillators and
synchronous pacing, and with the growing prevalence of chronic HIV infection and immunosuppression,
such opportunistic device infection may be a more commonly encountered infectious entity in years to
come.
435

NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Megha Sawhney,
MBBS
Chronic Cocaine Use Can Be Associated With Sick Sinus Syndrome
Megha Sawhney, MD Co-authors: Ankit Garg, MD Timothy Lane, MD Yashaswi Pokharel, MD
INTRODUCTION: The sick sinus node syndrome usually occurs because of nodal fibrosis and the
presentation frequently includes SA nodal pauses, arrest, and exit block. A sinus pause or arrest is
defined as the transient absence of sinus P waves on the EKG that may last from 2 sec to few minutes.
Chronic cocaine use can also produce sinoatrial block.This case demonstrates the presentation of sick
sinus syndrome in a man with chronic cocaine use.
CASE PRESENTATION: A 57 year old man presented to ED with syncope. He was walking to his
bathroom after waking up when he felt dizzy, lightheaded, and fell on the floor unconscious. He denied
any premonitory symptoms of chest pain, SOB, or palpitations. No history of seizures or head trauma
was obtained. Physical exam was unremarkable and orthostatics were normal. lnitial labs including CBC,
metabolic panel were normal. Imaging studies including CXR and CT- scan of the brain were negative.
Urine drug screen(UDS) was positive for cocaine. EKG showed bradycardia and normal PR, QRS and QT
interval. During his first night in the telemetry unit he was noted having 2 sinus pauses of >5 sec,
followed by few episodes with sinus pause >3sec on the second night when he was completely
asymptomatic. Permanent transvenous pacemaker was inserted on day 4. Previous hospitalizations for
chest pain related to cocaine also demonstrated bradycardia with similar sinus pauses. His 6 month
follow up did not show any new admissions for chest pain or syncope.
DISCUSSION: Cocaine induced bradyarrhythmias have not been described frequently despite the
common use of cocaine in US, but has clearly been described in multiple case reports of sinoatrial block.
Acute cocaine intoxication produces sinoatrial block. The mechanism of block is attributed to fall in the
resting potential and decrease in the amplitude and Vmax of phase 0 of action potentials of the resting
cardiac muscle fibres with automaticity. There may be several mechanisms for electrophysiological
changes that include depressed SA nodal automaticity, SA nodal exit block, spasm of sinoatrial artery,
inferior MI, chronic ischemia and resulting fibrosis of the SA node. Our patient received a permanent
pacemaker because of recurrent and persistent nature of this association. The physicians should be
aware that cocaine use can present with a sick sinus like syndrome and recurrent syncope.
436

OHIO POSTER FINALIST - CLINICAL VIGNETTE Kanchan V Landge, MD
Chapter Winning Abstract
Kanchan Landge MD, Sneha Kommoori MD, Sandeep Nagre MD, Raheel Jamal MD, Mahesh Pillai MD
INTRODUCTION:Central nervous system (CNS) involvement is a well recognized complication of
Epstein-Barr virus (EBV) infection, the most common form being encephalitis and CNS lymphoma. Rarely
EBV is also implicated in pathogenesis of vasculopathy. We describe a case of a young individual with
CNS vasculopathy caused by EBV who presented as acute ischemic stroke.
CASE PRESENTATION: Patient is a 35 year old male who presented with symptoms of severe headache
and loss of balance for one day. He has past medical history of ulcerative colitis, hypertension,
dyslipidemia and recent deep vein thrombosis. Initial assessment revealed stable vitals and normal
physical examination except left sided weakness. Investigations revealed normal complete blood count,
basic metabolic profile, liver function tests, coagulation parameters and chest radiograph. Magnetic
resonance imaging of the brain showed acute ischemia versus neoplasm in the corpus callosum, right
basal ganglia and anterior aspect of right thalamus. Patient was started on intravenous dexamethasone
and neurosurgery was consulted for possible biopsy. Also, computed tomography scan of the brain with
contrast was obtained to rule out hemorrhage which showed a rim-like contrast enhancement
suggestive of an abscess. In the meantime his motor function continued to worsen and he spiked fever.
Pathology from the stealth biopsy of the frontal mass showed subacute encephalomalacia with reactive
and inflammatory changes, subacute vasculopathy with thrombosis and acute cerebral infarct with EBV
probe positive. The EBV serology showed reactivation pattern. Patient was discharged to acute
rehabilitation on acyclovir. His strength improved markedly after few months of physical therapy.
DISCUSSION: The role of EBV in pathogenesis of vasculitis has been speculated previously but what
makes our case unique is the subacute vasculopathy and the fact that both endothelial cells and cells
within the walls of the blood vessel were positive for EBV and those same blood vessels were
thrombosed. As all the work up to determine any secondary cause of vasculopathy was negative in this
patient, we conclude that the most likely etiology was EBV infection. This case emphasizes the
recognition of growing spectrum of diseases caused by EBV.
437

OHIO POSTER FINALIST - CLINICAL VIGNETTE Shubhi Agrawal, MD
Headache in a young female
Shubhi Agrawal, MD
INTRODUCTION: Headache is a very common yet challenging problem. The constellation of symptoms
among various diagnoses is often overlapping and presentation can be varied. Here we report a case of
headache in a healthy teenager.
CASE PRESENTATION: A 17 year old Caucasian female presented to our hospital with complaints of
severe throbbing, fronto-temporal headache for 5 days; associated with photophobia, nausea and non
projectile vomiting. The patient and her parents denied any history of fever, seizures or altered mental
status. There was no personal or family history of migraine. On examination she was alert, fully oriented
and vital signs were stable. Neurological exam including higher mental functions, cranial nerves, motor
and sensory systems, coordination and gait was normal. There was marked photophobia but pupillary
size and reflexes, external ocular movements, visual fields and fundoscopy were normal. Presence of
neck rigidity was questionable but Kernig's sign was absent. Examination of the skin, lymph nodes,
oropharynx, cardiorespiratory system and abdomen was benign. A non-contrast computerized
tomographic scan of the brain was unremarkable. Complete blood count and basic metabolic profile
were normal. A diagnosis of Status Migrainosus was made and dexamethasone and promethazine were
administered. However, there was minimal symptom relief. Later, the family physician reported a fever
of 102 F two days prior, so a lumbar puncture was performed. Cerebrospinal fluid was clear, with
opening pressure of 300 mm of water, nucleated cell count of 580 cells with 94%lymphocytes, glucose
of 42mg/dl (blood glucose 107mg/dl) and proteins of 157mg/dl. Headache and nausea were much
relieved by the procedure and intravenous acyclovir was started empirically. CSF studies for
Cryptococcal antigen, India Ink preparation, VDRL, FTA, Herpes Simplex PCR, Gram Stain and cultures
were negative. On the third day, a painless, fine, red, maculo-papular rash appeared over the right C7
dermatome. She also gave a history of chicken pox at the age of 3 years. So PCR for Varicella Zoster virus
was ordered and was positive. She was discharged home on intravenous acyclovir for 10 days and
reported complete recovery.
DISCUSSION: Neurological complications from reactivation of Varicella Zoster virus have been
described extensively in immunocompromised and elderly patients but rarely in young
immunocompetent patients. Due to its indolent course it is likely to be misdiagnosed in the latter group,
especially in the absence of a typical rash. Also, patients often take over the counter medications like
Paracetamol and Ibuprofen for headache, that may mask fever, further complicating the diagnosis.
Timely diagnosis is imperative as it is a treatable condition that can potentially lead to complications like
encephalitis and cerebral vasculitis among others.
Also, the possibility of subclinical meningitis in all patients with Herpes Zoster needs to be investigated
further.
438

OHIO POSTER FINALIST - CLINICAL VIGNETTE Abidemi Bobby Akande, MD
Troubling Spinal Osteomyelitis: Candida In An Immunocompetent Patient
Abidemi Bobby Akande, M.D., M.P.H. Other authors: John S. Czachor, M.D., Alpa Desai, MBBS. Wright
State University Department of Internal Medicine
INTRODUCTION: Significant Candida infections are quite rare in immunocompetent patients without
known risk factors. 1 Candida osteomyelitis of the spine in non-intravenous drug users is exceedingly
rare, with only 59 cases reported in the literature between 1966 and 2000. 2,4,5 We report a case of
Candida albicans osteomyelitis in a previously healthy 30-year-old Caucasian male with no apparent risk
factors for fungal infections.
CASE PRESENTATION: A 30-year-old male presented to emergency room (ER) with a chief complaint of
back pain. Diagnosed as back strain, he was discharged with analgesics but returned several times back
to the ER. The patient had complaints of significant stabbing mid-back pain described as intermittent,
aggravated by movement and relieved by rest. There was no fever or chills. Although he initially denied
night sweats, he later reported several episodes. He is a tree trimmer by profession but denied history
of penetrating injury. He repeatedly denied a history of intravenous drug use. Physical exam was
significant only for tenderness to palpation in the T5-10 vertebrae level. His neurological exam was
unremarkable and there were no findings to suggest needle punctures or skin infections. An MRI
showed thoracic spine disease consistent with osteomyelitis, diskitis and left paraspinal abscess at the
T10-11 level. Percutaneous paraspinal aspirate isolated only Candida albicans. Treatment was started in
the hospital with high dose fluconazole and the patient was discharged on fluconazole 400 mg orally
daily. He was re-admitted 1 month later for worsening back pain and underwent surgical debridement
of the affected area. Again, C. albicans was the only organism isolated. He was discharged once again on
fluconazole which he continued for 3 months to complete his course of therapy. He remains clinically
free of infection at this time.
DISCUSSION: The majority of Candida osteomyelitis cases involve the lower thoracic and upper lumbar
vertebrae, as evidenced by this patient. In contrast, however, is that the age predominance is mostly
amongst middle-aged individuals. 2 Greater than eighty percent of patients complain of back pain. 2,3
Diagnosis is often delayed due to the insidious onset and the relatively non-infectious presentation of
this entity. 5,7 Candida albicans is the most frequent isolate of all the Candida species. 4 Risk factors for
invasive infections include immunocompromised states such as HIV/AIDS, glucocorticosteroid
administration, cancer chemotherapy, neutropenic states, recent use of broad spectrum antibiotics;
injection drug use, and indwelling venous catheters. 7 No such risk factors were identified in this case.
Prolonged antifungal therapy is essential for successful treatment of Candida osteomyelitis. 6 There is
usually a good response to fluconazole. 6 Significance of follow up MRI with worsening disease despite
clinical improvement remains unclear. 8 The role of surgery remains to be further delineated. 8 It was only
after surgical debridement that our patient had steady improvement.
439

OHIO POSTER FINALIST - CLINICAL VIGNETTE Sado Al Bitar, M.D.
A CASE OF AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME
Sado Al Bitar, M.D., Kim Jordan, M.D.
INTRODUCTION: INTRODUCTION: Autoimmune Lymphoproliferative Syndrome (ALPS) is a relatively
new disease first described in 1995. This inherited immunodeficiency disorder is considered a pediatric
illness, generally diagnosed before age 5, but the disease can present in adulthood. Abnormal
lymphocyte apoptosis and lymphoid cell accumulation lead to lymphadenopathy, hepato- splenomegaly,
hypergammaglobulinemia, and autoimmune disease. The incidence of lymphoma is significantly
increased. Though ALPS is rare in adulthood, internists should be cognizant of its presentation,
treatment, and offer genetic counseling if diagnosed.
CASE PRESENTATION: Case: A 42 yo female with a history of psychotic disorder presented with 3 days
of left upper quadrant abdominal discomfort, preceded by 3 weeks of diarrhea. Stool was watery,
brown, with no blood or mucus. She had no other complaints. Examination revealed tender
splenomegaly, but no lymphadenopathy or hepatomegaly. Mild anemia (Hb 11.4), low IgA (21) and
elevated LDH (154) were noted. Stool culture was positive for Blastocystis hominis, which was
considered a colonizing organism, was not treated, and her diarrhea subsided within 1 day of
admission. Imaging showed massive splenomegaly, mesenteric and retroperitoneal lymphadenopathy.
Bone marrow revealed erythroid hyperplasia, but was negative for abnormal lymphoid population by
flow cytometry immunophenotyping. Splenectomy was performed and pathology showed T-zone
hyperplasia with reactive immunoblasts featuring a phenotypically distinct T-cell population, suggestive
of ALPS.
DISCUSSION: DISCUSSION: ALPS is a genetic disorder characterized by a defect in the tumor necrosis
factor receptor gene superfamily ( TNFRSF6) which encodes for the Fas cell surface receptor and T cells
that express alpha-beta T-cell receptor, but are CD 4 and CD 8 negative. The Fas cell surface receptor
plays a major role in lymphocyte apoptosis. Defective apoptosis leads to accumulation of
immunogenic “alpha-beta double negative T-cells” in the peripheral blood and lymphoid organs, with
resultant splenomegaly, lymphadenopathy, and possible autoimmune cytopenias. The incidence of
lymphoma (Hodgkin and non Hodgkin) is significantly increased. The clinical presentation of individuals
with ALPS is highly variable; penetrance depends on site of mutation. Several subtypes exist
including: ALPS-FAS (most common); ALPS-sFAS (somatic mutation); ALPS-LG (ligand mutation); ALPS-
CASP10 (caspase 10 mutation); and ALPS-U (genetic mutation unidentified). Definitive diagnosis
requires presence of non-malignant, non-infectious lymphadenopathy in 2 nodal chains, and/or
splenomegaly for 6 months, plus abnormal lymphocyte apoptosis assay and/or presence of FAS pathway
genetic mutation. Many patients require no treatment though genetic counseling is recommended
given the increased association of malignancy and autoimmune disorders. Splenectomy may be needed
in cases of severe hypersplenism, as well as glucocorticoid therapy for autoimmune hemolytic anemia
and thrombocytopenia. IVIG, cyclosporin A, and methotrexate patients have been used to treat
immune cytopenias refractory to splenectomy and steroid treatment.
440

OHIO POSTER FINALIST - CLINICAL VIGNETTE Rasha Al-Bawardy, MD
Sore Throat and Fever… Look Beyond Infection!
Rasha Al-Bawardy, MD, M Chadi Alraies MD FACP
INTRODUCTION:Infectious mononucleosis (IM) is a self-limiting disease caused by Epstein-Barr virus
(EBV). Patients usually present with malaise, fatigue, fever, lymphadenopathy and pharyngitis. IM can
cause a reactive proliferation of lymphocytes that could mimic large granulocytic lymphocyte (LGL)
leukemia. We report a case of atypical IM with absolute neutropenia, LGL lymphocytosis simulating LGL
leukemia.
CASE PRESENTATION: A 42-year-old man who works for the Justice Department stationed in Ghana
presented with 3-day history of headache, fatigue, fever (105°F) and sore throat. He was treated with
anti-malarial and antibiotics. Few weeks later, fever continues with drenching sweats and was flown to
the US for further work up. On presentation to our hospital he was afebrile, had few small submental
lymphadenopathy, oral thrush and papular rash on his back. Laboratory findings were significant for
WBC 3.0k/uL, absolute neutrophil count (ANC) 0, hemoglobin 12.9g/dL, platelets 587k/uL, normal
electrolytes, and elevated CRP12.2 mg/dL. Peripheral blood smear showed many large granular
lymphocytes and 19% LGL on flow cytometry. He had elevated EBV-IgG >8AI (normal
DISCUSSION: Neutropenia and increased LGL levels is a rare presentation of infectious mononucleosis
which mimics LGL leukemia. LGL is an uncommon type of leukemia that has few subtypes, some with
rapid deterioration. The diagnosis of LGL leukemia is based on the presence of an LGL lymphocytosis,
characteristic immunophenotype, and confirmation of clonality using TCR gene rearrangement studies.
Reactive LGL lymphocytosis can be seen in viral infections but the differentiation between reactive and
true LGL leukemia can be challenging. In most reported cases of atypical infectious mononucleosis there
is no evidence of T-cell monoclonality. To our knowledge, this is a unique case of infectious
mononucleosis with mild expansion of TCR-VB14. In this case, given the spontaneous recovery and the
unusual immunophenotype expression lead to the diagnosis of Infectious mononucleosis.
441

OHIO POSTER FINALIST - CLINICAL VIGNETTE S Bajaj Navkaranbir, MD
Anion gap acidosis with osmolar gap - not always poisoning.
S Bajaj Navkaranbir, MD 1 Second Author: Bandyopadhyay Debabrata MD1 Third Author:Priyanka
Sharma MD FACP 2 1 Department of Internal Medicine Cleveland Clinic, 2 Department of Hospital
Medicine
INTRODUCTION:Organic acidemias, also known as organic acidurias are group of metabolic disorders
resulting from enzyme deficiency, usually present in the newborn period or early childhood. We report a
rare case of late onset glutaric aciduria- type 2(GA-2) in a 42- year old Caucasian female presenting as
unexplained anion gap metabolic acidosis with osmolar gap.
CASE PRESENTATION: A 42-year-old Caucasian female with no significant medical history presented to
our emergency department (ED) with malaise for 2 days, nausea, vomiting and confusion for a day. Her
history was negative for any fever, toxic ingestion, liver disease, diabetes, psychiatric disorder, recent
prescription medication or drug use and symptoms of neurological deficit. Her detailed review of
symptoms ,past medical, family and treatment history were non contributory. Her physical examination
was significant for sinus tachycardia, signs of dehydration, confusion, somnolence and loss of
orientation to time place and person. No meningeal or focal neurological signs were present on physical
examination and rest of the physical examination was benign. The intial work up for confusion in the ED
revealed anion gap metabolic acidosis. Further evaluation revealed she had serum osmolar gap with
elevated serum osmolarity and high urinary anion gap. Additional laboratory work up revealed she had
low blood glucose, low TSH, high free T3, free T4, high ammonia levels and ketones in her serum. Her
toxicology studies were negative for any common toxins. She underwent urgent dialysis for possible
toxic ingestion and improved. Her metabolic profile was elusive for any common cause of metabolic
acidosis but suggestive of inborn error in metabolism driven by catabolic state driven by
hyperthyroidsm. Further diagnostic work revealed she had elevated urinary glutaric acid, 2-OH gluatric
acid, 2-OH gluatric lactone, ethylmalonic acid, isovalerylglycine, hexanoylglycine and suberylglycine
suggestive of GA-2. She also had low serum carnitine levels. She underwent genetic testing for GA-2
mutations which revealed she is heterozygous for 2 sequence changes of ETFB gene which codes for
multiple acyl CoA dehydrogenase (MADD) the enzyme deficient in GA-2. Further evaluation of her
deranged thyroid function revealed she had Grave’s disease and underwent total thyroidectomy and is
currently on levothyroxine replacement. She is currently being treated with carnitine for GA-2 and is
asymptomatic
DISCUSSION: GA-2 is a very rare autosomal recessive disorder which usually presents in early
childhood. Our patient who was heterozygous for this disorder became encephalopathic, hypoglycemic,
ketotic and hyperammonemic from excessive production of organic acids due to relative deficiency of
MADD due to hypermetabolic state precipitated by hyperthyroidism.
442

OHIO POSTER FINALIST - CLINICAL VIGNETTE Muhammad Bawany, MD
Unusual Cause Of Obscure Overt Gastrointestinal Bleeding Diagnosed With Spirus Enteroscopy In
Patient With Tuberous Sclerosis
Muhammad Bawany, MD Co- Authors: Soukayna Rkaine, MD., Ali Nawras, MD. FACG
INTRODUCTION: Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by
the development of benign neoplasms (hamartomas) of the skin and internal organs. It involves the
neurological system in most cases, in addition to the skin, the kidneys and the lungs. The Involvement of
gastrointestinal (GI) system is uncommon, rarely of clinical relevance, and not well described in
literature. This involvement varies from benign angiomyolipomas, neuroendocrine tumors, hamartomas
polyps and stromal tumors to invasive rectal adenocarcinoma. We report a patient known to have TSC,
presented with recurrent obscure overt gastrointestinal bleeding due to a large Jejunal submucosal
undifferentiated tumor diagnosed by Spirus enteroscope.
CASE PRESENTATION: A 39 years old Caucasian female, known to have TSC with multi-organ
involvement including kidney, lung and liver, presented to our hospital with a complaint of melena for
three days. She denied any abdominal pain, nausea, vomiting hematemesis or hematochezia. On
physical examination, she had normal vital signs. The abdomen was soft, nontender with positive bowel
sounds. Her blood test revealed hemoglobin of 6.7 g/dl and hematocrit of 20. Prior to this episode the
patient had recurrent episodes of obscure overt GI bleeding in the form of melena over the course of
one year. She had two previous upper endoscopies revealing multiple small polyps in the stomach and
duodenum. None of the polyps had stigmata of bleeding. She also had two negative colonoscopies. The
patient was admitted to the hospital, received blood transfusion and underwent upper gastrointestinal
endoscopy, which revealed again multiple small non-bleeding sessile polyps in the stomach and
duodenum. The colonoscopy was unremarkable. Capsule endoscopy was done and revealed fresh blood
in the jejunum without identifying the source. Enteroscopy was then performed using spirus
enteroscope, which showed large (30 mm X 25 mm) submucosal, umbilicated and ulcerated mass at the
proximal jejunum. The mass was biopsied and the site was tattooed using India ink. The biopsy was
unremarkable. Surgical resection of the mass was then performed. The gross pathology of the mass
revealed 67 mm X 30 mm well circumscribed submucosal gray-white mass with a wall thickness of 0.3
cm. The immunostains that might be helpful in delineating its nature were negative. The pathological
diagnosis of the mass was reported as undifferentiated malignant neoplasm. Up to date (6 months post
surgical resection) the patient had no further episodes of GI bleeding and her Hemoglobin level stayed
normal.
DISCUSSION: To our knowledge, our patient is the first reported patient with TSC and large
undifferentiated malignant neoplasm of the jejunum causing significant recurrent obscure overt GI
bleeding and the first to be diagnosed by using Spirus enteroscope and then successfully treated
surgically.
443

OHIO POSTER FINALIST - CLINICAL VIGNETTE Keaton M Bullen, DO
A Crippling Presentation Of Neurofibromatosis I
Keaton M Bullen, DO, PGY-2 Second Author: Rex Wilford, DO, RPh
INTRODUCTION:Neurofibromatosis type 1 (NF-1) is an autosomal dominant neurocutaneous disorder
characterized by peripheral neurofibromas, axillary freckling and cafe-au-lait spots. Most NF-1 patients
are diagnosed in childhood. Though it is a relatively common disease, cervical cord compression from
plexiform neurofibromas is a sporadic finding in these individuals. We present an adult with previously
undiagnosed NF-1 with neurologic deficits from plexiform neurofibroma induced cervical cord
compression.
CASE PRESENTATION: A 43-year-old African American male, with no known past medical history,
presented with upper and lower extremity weakness, paresthesias and spasticity. Years prior, he had
been seen multiple times in the emergency room for back pain and burning sensations, but never had a
complete neurologic workup. His most recent symptoms began with lower extremity weakness seven
months prior to arrival, which progressed to proximal lower extremity contractions and inability to
ambulate. He denied family history of neurologic disease. Physical exam revealed decreased muscle
strength in distal upper extremities and proximal lower extremities, mostly affecting grip strength and
hip flexors. Pateller reflexes were 3+ bilaterally and sensation was decreased in the distal
fingers. Dermatologic exam revealed extensive right-sided freckling and there were two large macules
present, which were consistent with cafe-au-lait spots.
Magnetic resonance imaging revealed bilateral plexiform neurofibromata expanding the neural
foramina from C2-C3 through C6-C7. There was a large pedunculated neurofibroma arising from C6-C7
and a complex mass compressing the cord from C2-C5. The patient underwent tumor debulking surgery
with posterior C2-C6 fusion. Microscopic exam of the surgical specimen revealed a lesion infiltrating the
peripheral nerve and sensory ganglion in a pattern suggestive of a neurofibroma. His postoperative
course was uneventful, and he was discharged to an acute rehabilitation facility with improving strength
and mobility in his previously affected extremities.
DISCUSSION: It is essential to recognize subtle signs of NF-1, such as axillary freckling and cafe-au-lait
spots, in patients without clinically obvious disease. Identifying NF-1 patients can allow early detection
and treatment of complications, such as cord compromising lesions, thus avoiding pain, weakness, and
even paresis. Plexiform neurofibromas causing cervical cord compression is a known consequence of
NF-1, but it is infrequently reported. Most case series include younger individuals and there is a strong
focus on the surgical management of the neurofibromas. There is still limited data regarding the natural
history of a benign neurofibroma, the utility of routine imaging, long-term prognosis, and the
importance of follow up for these individuals.
444

OHIO POSTER FINALIST - CLINICAL VIGNETTE Sriranjini Chilkunda
Ramaswamy, MD
Crohn's Disease versus Carcinoma of Bladder: A Diagnostic Dilemma.
Sriranjini Chilkunda Ramaswamy, MD, Jasleen Kaur Pannu, MD, Hardeep Rai, MD,Richard Nord, MD,
Lawrence Goldstein, MD, FCCP.
INTRODUCTION:Inflammatory bowel disease (IBD) has been known to bear a wide array of extra
intestinal manifestations(EM) and complications. It is also known to be an independent risk factor for
genitourinary malignancies. Benign tumors of urinary bladder occurring in association with Crohn’s
disease have been rarely reported. These “cancer mimics” pose a perplexing diagnostic dilemma for
clinicians. We report a case of a young man with Crohn’s disease who presented with a benign bladder
mass as an extraintestinal manifestation of his disease.
CASE PRESENTATION: A 42 year old white male diagnosed with Crohn’s disease one year prior
developed dysuria associated with bilateral inguinal discomfort and constipation. Physical examination
was normal. He was evaluated with a CT of the abdomen using a renal stone protocol. No stones were
identified but inflammation was noted in the region of the terminal ileum. A subsequent colonoscopy
revealed a normal colon but a stricture was noted in the terminal ileum. Small bowel follow through
confirmed severe narrowing of the terminal ileum. The pain responded to metronidazole but multiple
recurrences required treatment with metronidazole then ciprofloxacin. Recurrent symptoms a year later
led to a repeat urologic evaluation which was notable for hematuria on urinalysis. A subsequent
cystoscopy revealed a mass in the dome of the bladder. Repeat cystoscopy two months later
demonstrated a persistent but less inflamed appearing mass. Subsequent biopsy was read as a
superficial low grade urothelial carcinoma. During this period abdominal discomfort and dysuria
associated with bowel irregularities waxed and waned. A follow-up abdominal CT revealed an
inflammatory mass in the right lower quadrant from the terminal ileum to the dome of the bladder
without definitive fistula formation. Due to persistent right lower quadrant discomfort and constipation
with the above CT scan findings, consultation with a colorectal surgeon was undertaken but surgery was
deferred because of the urologic issue. Subsequent bladder tumor fulcurization revealed fibrovascular
tissue, smooth muscle and adipose tissue with acute and chronic inflammation and reactive features
with no evidence of carcinoma.
DISCUSSION: Radiographic and cystoscopic evidence of bladder mass is most commonly known to
represent carcinoma. Rarely, Crohn’s disease may present with a bladder mass as a result of
compression by an enlarging intrabdominal focus of inflammation. But, the fact that Crohn’s disease is
an independent risk factor for transitional cell carcinoma of bladder can not be ignored. Meticulous
pathology interpretation following biopsy is warranted to differentiate low grade cancers from severe
inflammation.Also regional enteritis should be considered an important differential in healthy adults
with bladder mass and no risk factors for carcinoma of bladder.
445

OHIO POSTER FINALIST - CLINICAL VIGNETTE Ayham Deeb, MD
Mixed Autoimmune Hemolytic Anemia presented after Chronic Rejection of Kidney Transplant - A
Case Report.
Ayham Deeb, MD
INTRODUCTION: Mixed Autoimmune hemolytic anemia (AIHA) is uncommon, it can cause severe
hemolysis which could be responsive or resistant to conventional treatment with steroids or
plasmapheresis. Fifty percent of cases are idiopathic; the reported associated disorders are SLE or
Lymphoma. We report an interesting case in a patient who developed mixed AIHA after recent chronic
rejection of a transplanted kidney and withdrawal of immunosuppressant medications.
CASE PRESENTATION: A-72-year -old Caucasian female with a known history of end-stage kidney
disease was sent to the hospital by her nephrologist regarding abnormal blood work after hemodialysis.
There was a significant drop of her hemoglobin. The patient had her usual hemodialysis treatment two
days before without complications and with a clear hemodialysis filter. When she returned home, she
was much weaker than usual. She did not have any fever, chills, melena or gross hematuria. Upon
presentation, blood pressure was 144/67 mmHg, pulse 80 beats/min, temperature 97.4F, respiratory
rate 18/min, and oxygen saturation was normal. Her physical exam was completely normal. Laboratory
data was significant for low hemoglobin level of 4.86 g/dl, Platelet count of 311 x 10 9 /l and a WBC of
11x 10 9 /l. Further evaluation revealed too numerous red blood cells in the urine. Total bilirubin, SGOT
and LDH were elevated, while haptoglobin and complements were abnormally reduced. A direct
antiglobulin test was positive with serological detection of cold and warm antibodies, and the patient
was typed as blood group A with positive alloantibodies. Tests to exclude viral, bacterial and connective
tissue diseases were all negative. Treatment with dexamethasone and blood transfusion was adequate
to bring up and stabilize the hemoglobin close to her baseline on the following days and after discharge.
Our patient has a deceased donor kidney transplant in 2004, which lost function two months before this
admission. Diagnostic biopsy showed moderate to severe tubule interstitial nephritis and staining with
IgG, IgM and C3. After rejection hemodialysis was initiated, Prednisone and Mycophenolate mofetil
were stopped and Cyclosporin dose was decreased.
DISCUSSION: Mixed-type autoimmune haemolytic anaemia (AIHA) is rare, the etiology could be
idiopathic or secondary to associated clinical conditions. In mixed type AIHA prompt treatment with
steroids is successful, but there are aggressive forms unresponsive to steroids, in these cases underlying
lymphoma should be ruled out, treating the lymphoma can be adequate. There are reported successful
trials of using Rituximab in the aggressive forms, otherwise splenectomy is indicated. Diagnosis could be
challenging as the cold agglutinin titre is low in mixed AIHA.
In this case we demonstrate the occurrence of mixed AIHA secondary to the patient’s underlying
condition, and the successful treatment by using steroids.
446

OHIO POSTER FINALIST - CLINICAL VIGNETTE Dheeraj Goyal, MD, MPH
Non-giant cell temporal arteritis as an initial presentation of ANCA associated small-vessel vasculitis
Dheeraj Goyal, MD, MPH Supervisors (Coauthors): Vijay K. Mahajan, MD, Thurai Kumaran, MD
INTRODUCTION: Small vessel vasculitis and temporal arteritis are unknown to manifest together. We
report a case in which Myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) associated
small-vessel vasculitis presented as non-granulomatous, non-giant cell bilateral temporal arteritis.
CASE PRESENTATION: A sixty-seven year-old Caucasian female was admitted with painful rash. It was
acute in onset, progressive in nature, and became intensely pruritic with time. On examination, diffuse
maculo-papular rash was noted on both of her lower extremities with sparing of soles and genital areas.
She denied any ear, nose, throat or chest complaints. The rest of her clinical examination was normal.
Serum creatinine was 2.31 mg/dL. Blood Urea Nitrogen (BUN) level was 42 mg/dL. Urinalysis revealed 2+
proteinuria with no eosinophiluria. Erythrocyte Sedimentation Rate (ESR) was 68 mm/hour. Proteinase 3
anti-neutrophil cytoplasmic antibody (PR3-ANCA) level was normal and MPO-ANCA level was 1524
AU/mL (Normal < 100 AU/mL). The rest of the autoimmune workup was negative. Cryoglobulin C3 and
C4 levels were normal.
She was recently evaluated for frontal headache, low-grade fever and neck stiffness. The Cerebrospinal
Fluid (CSF) analysis and Magnetic Resonance Imaging (MRI) of the brain at that time were unremarkable.
Bilateral temporal artery biopsies revealed focal mural inflammatory infiltrates with disruption of
internal elastic lamina in the right-sided temporal artery. Interestingly, no giant cells or granulomas were
seen.
Renal biopsy revealed pauci-immune necrotizing glomerulonephritis without full crescent formation.
Small blood vessels in the renal cortex showed vasculitic changes with fibrinoid necrosis. No immune
complex deposition was noted. She was treated with intravenous Methylprednisolone pulse therapy for
three days. Her rash improved, and she was subsequently switched to oral Prednisolone and
Cyclophosphamide. However, her renal function did not show significant improvement. Low dose
Bactrim was started for Pneumocystis jiroveci pneumonia prophylaxis, and she was discharged to an
extended care facility (ECF).
DISCUSSION: Biopsy proven non-granulomatous, non-giant cell bilateral temporal arteritis in a patient
with biopsy proven MPO-ANCA associated small-vessel vasculitis is an extremely rare presentation.
Presence of giant cell(s) or granuloma(s) is not necessary to make a diagnosis of “temporal arteritis”. The
patient denied any vision changes. However, her age, presence of localized headache, elevated ESR
greater than 50 mm/hour, and biopsy proven necrotizing arteritis in her temporal arteries fulfill the
American College of Rheumatology, 1990 criteria for temporal arteritis. Furthermore, renal biopsy
findings strongly favor the presence of simultaneous microscopic polyangiitis (MPA).
This case is not only unique, but also challenges the common clinical practice of treating vasculitis
merely on the basis of size of affected vessels. The possibility of similar presentation should be kept in
mind while managing vasculitis.
447

OHIO POSTER FINALIST - CLINICAL VIGNETTE Ismail Hader, MD
Persistent Fever and A Single Positive Blood Culture: How Far Your Suspension Can Guide You?
Ismail Hader, MD Osama Amro, MD Ahmed Ibrahim, MD Khaldoon Shaheen, MD
INTRODUCTION: Our case emphasizes the importance of detection of HACEK group infective
endocarditis. Although persistent bacteremia is a major criterion for the diagnosis of Infective
Endocarditis, HACEK group organisms lack this feature since they are hard to grow on regular growth
media. A thorough cardiac examination and evaluation with trans-thoracic and esophageal
echocardiogram is a crucial step while initiating empiric antibiotics treatment.
CASE PRESENTATION: A 56 year old male presented with generalized body aches, chills and fever for
eight days. Symptoms were associated with palpitation, sweating, headache, and dry cough. He denied
any IV drug abuse. Physical exam showed tachycardia with irregularly irregular pulse, high grade fever of
40°C, precordium auscultation revealed normal heart sounds with no murmur. Site of pacemaker was
intact with no tenderness or erythema, Lung exam revealed bilateral crackles, Initial blood tests
revealed WBC of 12.400 with 22% band and hemoglobin of 10.1. ESR was 127. Chest X-ray showed
bilateral multiple pulmonary infiltrates and pleural effusions. Initial management included blood culture
and empirical antibiotics for presumed community acquired pneumonia. On day five, one set of blood
culture grew Haemophilous Parainfluenzae. Transthoracic echocardiogram showed no vegetation.
Despite of the antibiotics management, he remained febrile with worsening body aches and lethargy. 12
sets of repeated blood cultures were negative. TEE was performed and showed large vegetation on the
tricuspid valve. The diagnosis of Haemophilous Parainfluenzae infective endocarditis complicated by
pulmonary septic emboli was made. He was treated with intravenous antibiotics for an additional
6 weeks. Physical examination, TEE and surveillance blood cultures were negative at the 3-month
follow-up, and the patient had been well since.
DISCUSSION: Numerous pathogens can cause infective endocarditis (IE), including Haemophilus
parainfluenzae. H. parainfluenzae is part of the HACEK group that may cause about 3% of the total
endocarditis cases, and is characterized by a subacute course and large vegetations. Infective
endocarditis has multifarious manifestations. Diagnosis can be challenging and its capacity to mimic
other conditions may obscure the outcome in those cases where classic manifestations are not evident.
In our case, we prematurely discounted the diagnosis of IE; despite he had no audible murmur and had a
single positive blood culture for HACEK pathogen out of fourteen sets, several other findings like
anemia, persistent fever, constitutional symptoms and elevated inflammatory markers, all these guided
us to initiate a workup for infective endocarditis . Furthermore, our case emphasizes the relative
insensitivity of the transthoracic echocardiogram and the importance of the transesophageal
echocardiogram for the diagnosis of endocarditis. Likely the presence of pacemaker as a foreign body
was only imminent risk factor in this case.
448

OHIO POSTER FINALIST - CLINICAL VIGNETTE Serge Harb, MD
Dysarthria and Ataxia in A 34–Year-Old Woman
Serge Harb, MD Second Author: Ali Ataya, MD Third Author: Terrie-Ann Benjamin MD Fourth Author:
Chadi Alraies MD FACP
INTRODUCTION: A 34-year-old previously healthy woman presented with a one week history of
dysarthria, verbal stuttering, ataxia and postural instability.
CASE PRESENTATION: She was admitted a week prior to a local hospital with retractabe vomiting and
severe dehydration. She was found to be hyponatremic with a sodium level of 110 mmol/L. The rest of
her laboratory work up results were within normal limits. Initially, she was treated with antiemetics for
her nausea and vomiting and with hypertonic saline for her hyponatremia. However, her serum sodium
levels stayed the same and she was started on Tolvaptan (vasopressin V2 receptor
antagonist). vasssporessin was started on TolvptanOnfOn the subsequent day her serum sodium level
had increased to 145 mmol/L. Later that day, she was discharged in a stable condition. Five days after
discharge, she presented to our hospital with slurred speech, verbal stuttering, dysnomia, neologism,
dysdiadokinesia, and dizziness. On physical exam, she had dysarthria and ataxia with no nystagmus. The
remainder of her examination was unremarkable. Her sodium level was normal. A CT scan of the brain
was negative for any acute pathology. This was followed by a T2-weighted MRI which showed bilateral
symmetrical hyperintensities in the putamen area and caudate nucleus with sparing of globus pallidus
which is consistent with extrapontine myelinosis. She was discharged afte few days of physiotherapy
and occupational therapy with mild improvement of her neurological sympotms.
DISCUSSION: Rapid correction of hyponatremia using Tolvaptan and hypertonic saline (>12 meq/dl in
24 hours) has been associated with extrapontine myeleinosis (EPM). EPM is a variant of Osmotic
Demelination Syndrome (ODS). This was formerly referred to as central pontine myelinolysis. However,
since demyelination does not necessarily involve the pons and usually more diffuse, the name has
changed to EPM . Involvement of the basal ganglia with sparing of the pons is characteristic for EPM,
which has been described in 10% of patients with ODS. It can present later (2-6 days) after rapid
correction of the serum sodium. In our patient, clinical and MRI features of pontine involvement were
absent. Clinically she was dysarthric and ataxic which is attributed to striatal dysfunction. These findings
have been reported in isolated cases of EPM. On MRI, extrapontine changes have been described in the
basal ganglia, cerebellum and white matter.
Conclusion: There is no proven effective therapy for EPM.Among patients with hyponatremia, it is
important avoid rapid correction of hyponatremia with hypertonic or V2 receptor antagonist
medication. Suggested rate of correction is less than 10 meq/L in the first 24 hours and less than 18
meq/L in the first 48 hours.
449

OHIO POSTER FINALIST - CLINICAL VIGNETTE Ahmed M Ibrahim, MD
Cocaine Induced Intermittent Left Bundle Branch Block: Emergent or Elective Coronary Angiogram?
Ahmed Ibrahim MD, Others :Khaldoon Shaheen , Osama Amro , Keyvan Ravakhah, M Chadi Alraies MD
FACP
INTRODUCTION: CASE PRESENTATION: A 67-year-old man presented to our ER complaining of typical
chest pain few minutes after smoking cocaine. Pain was retrosternal and radiating to left shoulder
associated with diaphoresis and nausea but no vomiting. On arrival, his vitals were stable But he was
diaphoretic and in mild distress. His physical exam was unremarkable. Initial EKG in ER showed sinus
tachycardia with no ischemic changes and cardiac markers were normal. He received benzodiazepine,
sublingual nitroglycerine, aspirin, calcium channel blocker, and oxygen. Despite of all actions taken,
chest pain persisted. Repeated EKG revealed new left bundle branch block (LBBB). En route to left heart
catheterization (LHC), patient reported resolution of chest pain. EKG was repeated in cath lab and
showed resolution of LBBB. LHC was cancelled and he was admitted to hospital. Nuclear stress test and
2D echo were normal. He was discharged after being pain free. 8 months later he was admitted with
similar presenation.LHC was done and showed normal coronaries.
DISCUSSION: Cocaine-associated chest pain (CACP) is associated with 250,000 annual ER visits in the
United States. The potential of cocaine to induce myocardial ischemia and coronary spasm has been
demonstrated both in vitro and in vivo. Surge of catecholamines, thrombosis and platelets activation
have been suggested as a mechanism for ischemia which likely has caused the LBBB in our patient.
Mechanisms of Intermittent LBBB include rate dependent block which usually occurs in diseased or
ischemic His-purkinge system. Other mechanisms include phase 3 block which is physiological and occur
in normal individual. Also, cocaine has been shown to have an immediate blocking effect of cardiac
sodium channels. Aspirin, benzodiazepines, nitroglycerin and calcium channel blockers should be
included in the treatment for patients presenting with CACP. The current ACC/AHA guidelines
recommend immediate cardiac angiography for patients who presenting with chest pain and new LBBB
after cocaine use. However, almost half of CACP patients have normal coronary angiograms.
Furthermore, LHC in the setting of cocaine abuse may lead to further worsening of coronary spasm in
some cases and worsening of myocardial ischemia. We are reporting a case of a patient who presented
with CACP and transient new LBBB that resolved with conventional treatment. Similar to our case, most
low risk patients with CACP do well with a low incidence of cardiovascular complications. CONCLUSION:
Cocaine can be associated with intermittent LBBB which is likely due to transient ischemia. Risk
stratification and frequent evaluation of patient with CACP help avoiding unnecessary and potentially
harmful procedures. The best long term management of CACP is cocaine cessation.
450

OHIO POSTER FINALIST - CLINICAL VIGNETTE Owais M Idris, MD
Rare Case of Pancytopenia
Owais Idris, MD, Associate, St. Vincent Mercy Medical Center, Toledo, OH Mushtaq Ashraf, MD, Uzair
Idris, MSIII, Mohammad Al-Nsour, MD
INTRODUCTION:Pancytopenia is seen commonly in patients with bone marrow infiltration and fibrosis,
and various types of myelosuppression, including immune processes and drug reactions. Although iron
deficiency is occasionally seen in patients with pancytopenia, severe iron deficiency directly causing
pancytopenia is rarely seen.
CASE PRESENTATION: A 51-year-old African-American female presented with sudden onset
numbness, tingling, and inability to ambulate. Patient had a history of asthma, GERD, and hypertension,
but was not on any medications. She complained of fatigue, easy bruising, and menorrhagia. Physical
exam was only significant for pale conjunctiva, reduced motor strength in bilateral lower extremities
with right worse than left, and mildly diminished patellar reflexes. Patient’s CBC showed pancytopenia
with a WBC of 2.4k/µL, hemoglobin (Hgb) of 3.5g/dL, hematocrit (Hct) of 12.0%, mean corpuscular
volume (MCV) of 63.7fL and platelets (Plt) of 48k/µL. Differential showed a decrease in both absolute
lymphocyte count (ALC) and absolute neutrophil count (ANC), 0.70k/µL and 1.22k/µL, respectively.
Other blood work, including basic metabolic profile, thyroid function test, liver function test, and
autoimmune workup were normal. CT and MRI of the lumbar spine and brain were negative. Ultrasound
of the abdomen showed normal spleen, liver, and gallbladder, while pelvic ultrasound pelvis showed an
enlarged uterus with diffuse leiomyomatous involvement. Her anemia workup showed an iron level of
13µg/dL, total iron-binding capacity of 375µg/dL, iron saturation of 3%, and ferritin of 2µg/L with normal
vitamin B12 and folate levels, while fecal occult blood tests were repeatedly negative. Epstein-Barr virus
and parvovirus antibody panels showed previous exposure with no active infection. A bone marrow
biopsy showed a hypercelluar marrow with 80% cellularity, while iron-stained smear was negative for
iron stores. Patient received emergent packed red blood cell transfusions and was started on IV iron
sucrose. Her symptoms improved significantly, and she was able to ambulate without any assistance.
The cause of her severe iron deficiency was found to be menometrorrhagia, and she subsequently
underwent total abdominal hysterectomy. She was discharged on oral ferrous sulfate 325mg three
times a day. Her repeat CBC 3 months later showed her pancytopenia resolved. Her WBC was 6.9k/µL,
Hgb was 13.4g/dL, Hct was 40.5%, MCV was 90.8fL, Plt were 165k/µL, ALC was 1.10k/µL, and ANC was
4.40k/µL.
DISCUSSION: This case illustrates that severe iron deficiency can solely cause pancytopenia in the
general population. In addition to ruling out underlying pathology, such as malignancy, iron deficiency
should be given diagnostic consideration in patients presenting with pancytopenia without any obvious
cause. Evaluation can be easily performed by simple blood testing, and iron replacement therapy can
improve, and even resolve the condition.
451

OHIO POSTER FINALIST - CLINICAL VIGNETTE Owais M Idris, MD
Late Presentation of Familial Coagulopathy
Owais Idris, MD, Associate, St. Vincent Mercy Medical Center, Toledo, OH Vikram Aggarwal, MD,
Esmeralda Gutierrez-Asis, MD, Ricardo de Leon, MD, Mushtaq Ashraf, MD, Uzair Idris, MSIII, Mohammad
Al-Nsour, MD
INTRODUCTION:Inherited factor VII deficiency is a rare autosomal recessive disorder, which has an
incidence of 1 in 500,000 with only about 200 reported cases. It is primarily seen in countries where
consanguineous marriages are common.
CASE PRESENTATION: A 71-year-old Middle Eastern male presented with diffuse abdominal pain,
hematochezia, and generalized weakness. He had a surgical history that included hemorroidectomy,
transuretheral resection of the prostrate, cystoscopy with dilatation of urethral stricture, inguinal hernia
repair, and dental extractions. There were no complications during these procedures, including
excessive bleeding. He did, however, report spontaneous bilateral shoulder hemarthroses, beginning in
his early 50s. On physical exam, patient had a reducible inguinal hernia, but no purpura. His CBC
revealed hemoglobin (Hgb) was 8.6g/dl with a normal platelet count. Furthermore, he had prothrombin
time (PT) greater than 150 seconds and international normalized ratio (INR) greater than 17.0 with a
normal partial thromboplastin time (PTT). Patient’s past medical records showed his Hgb was 14.8g/dl in
2006. Upon further questioning, patient stated two of his five brothers, who live in Lebanon, have a
“bleeding” disorder since childhood and require subcutaneous injections to stop bleeding episodes.
Patient was worked up for coagulopathy. His liver function tests were normal, mixing studies showed no
evidence of circulating anticoagulant, and lupus anticoagulant screen was also negative. Based on
laboratory testing and family history, clinical suspicion of factor VII deficiency was entertained. Factor VII
activity was measured and was less than 10%, which was confirmed with repeated testing. Records were
obtained from his brothers, which showed both had severe factor VII deficiency with levels less than 2%,
and used recombinant factor VIIa (NovoSeven®) subcutaneous injections on as needed basis. Patient
received 6 units of fresh frozen plasma (FFP) and an esophagogastrodudenoscopy was performed that
revealed a duodenal ulcer. Patient’s condition improved with proton-pump inhibitor therapy and he was
discharged without any further bleeding episodes, even though his PT and INR were immeasurably high
after temporary normalization with FFP administration. Patient could not afford Novoseven® and was
advised to visit the nearest ER for any bleeding episodes.
DISCUSSION: This case illustrates striking differences in clinical phenotype, including a late
presentation of factor VII deficiency in our patient, who has two brothers with childhood-onset of the
same disorder. Compound heterozygosity can explain such variable expression of disease, including lateonset
forms. Genotype-phenotype relationships indicate the presence of major environmental or
extragenic components modulating expressivity. This case also highlights family history as an integral
part of diagnosis, and shows that it can help direct appropriate treatment.
452

OHIO POSTER FINALIST - CLINICAL VIGNETTE Kalipraveena NV Iruku, MD
Streptococcus Bovis: A rare etiology of epidural abscess
Kalipraveena NV Iruku, MD
INTRODUCTION: INTRODUCTION: Spinal epidural abscess is a rare but fatal condition requiring
immediate diagnosis and intervention. It is commonly seen in the thoracic and lumbar spinal cord
regions in patients with history of diabetes mellitus, intravenous drug abuse, alcoholism, epidural
anesthesia, recent surgeries to spinal cord and trauma to the spinal cord along with other comorbidities
like HIV. We want to describe a very rare etiology of cervical epidural abscess in an immunecompromised
patient isolating Streptococcus bovis from cultures of pus in the abscess.
CASE PRESENTATION: CASE PRESENTATION: A 41 year old African American male patient with past
medical history of Diabetes and hypertension presented to the ER with complaints of bilateral upper
limb numbness followed by weakness from 2 days and neck pain from 2 weeks. The patient was seen at
another hospital for similar complaints in the previous week and was prescribed Percocet for cervical
spasm. There is no history of fever except one episode of chills. No history of intravenous drug abuse,
alcohol intake, recent surgery or trauma to cervical area. The patient was sent for an immediate CT scan
which revealed diffuse subcutaneous edema, when the patient was referred for an emergent MRI which
showed an abscess with cervical cord compression at the level of C3 –C4. The patient underwent an
emergent evacuation of abscess and C3- C4 partial corpectomy with C3-C4 anterior cervical fusion.
During the surgery, the patient had quadriparesis secondary to spinal shock. The abscess fluid was sent
to culture and sensitivity along with the degenerated disk. The patient was initially treated with
vancomycin, linezolid and zosyn. The culture and sensitivity report isolated heavy growth of
streptococcus bovis from the abscess without any bacteremia and it was sensitive to ampicillin and
penicillin. The antibiotics were changed according to the culture and sensitivity. The patient recovered
well post operatively and regained power of 5/5 in lower limbs and strength of 3-4/5 in his upper limbs
3-4 days after surgery. 2D echocardiogram was done which showed no evidence of any vegetations.
Colonoscopy was done and was normal without any evidence of polyps or masses. The source of
infection from Streptococcus bovis remains unanswered. The patient was sent to skilled nursing facility
for physical therapy and administration of antibiotics.
DISCUSSION: There are only a few case reports of brain abscesses or subdural empyema caused by
Streptocccus bovis besides its well acknowledged causation of septicemia and endocarditis. In this
patient no associated lesion was detected and the etiology of Streptococcus bovis in our patient remains
uncertain. It is very important that our patient is followed up in the future with complete work up for an
occult malignancy including a repeat colonoscopy.
453

OHIO POSTER FINALIST - CLINICAL VIGNETTE Navjot Kaur, MD
HEMODIALYSIS CURES BLEEDING,ONE MORE REASON TO DIALYZE
Navjot Kaur MD, Vikram Aggarwal MD,Molly Litvin MD,Syed M. Abdi MD,Bikram S.Johar MD.
INTRODUCTION:Anticoagulation for cardiopulmonary bypass (CPB) in patients with Heparin induced
thrombocytopenia can be achieved with direct thrombin inhibitors (DTI) such as bivalirudin.
However,unlike heparin,there is no single reversal drug for DTI, which poses a risk of serious bleeding
after CPB. Our case describes a unique approach to successfully deal with such challenging situation.
CASE PRESENTATION: 61 yr male was admitted with worsening dyspnea, syncopal events and lower
limb edema for 1 month. He had past medical history of hypertension, Insulin dependent diabetes
mellitus, atrial fibrillation and end stage renal disease, on maintenance hemodialysis for 2 years. On
evaluation,trans-esophageal echocardiography revealed severe aortic stenosis (valve area 0.50 cm2
),aortic insufficiency, moderate tricuspid regurgitation & severe pulmonary hypertension. Cardiac
catheterization revealed normal coronaries with LVEF 45-50%. He was diagnosed to have HIT during
hospitalization. Thrombocytopenia recovered on withholding Heparin.
He underwent Cardiopulmonary bypass for aortic valve replacement with St. Jude valve and tricuspid
valve annuloplasty. Bivalirudin was used during surgery in view of recent diagnosis of HIT. His baseline
kaolin activated clotting time (ACT) was 116 s. After initial bolus of 0.75 mg/kg of Bivalirudin,continuous
infusion of 0.25 mg/kg/h of Bivalirudin was started with goal ACT > 300 s as per the protocol for dialysis
patients. He received 4 intermittent boluses of 0.5 mg/kg of Bivalirudin. Estimated blood loss was 5000
ml and patient was transfused 2500 ml of PRBC. Post-operative course was complicated by persistent
refractory bleeding from incision sites and chest tube drains. Disseminated intravascular coagulation
workup was negative.He received multiple FFPs, platelets, PRBCs, cryoprecipitates and even
recombinant factor 7 .In view of his uncontrolled bleeding, hemodialysis using High-flux polysulfone
dialyzer was instituted emergently 5 hours postoperative in order to remove bivalirudin.There was no
other indication for emergency hemodialysis. ACT dropped from 439s to 180s within 3 hours of dialysis.
Hemodialysis was stopped once bleeding stopped and chest tube output ceased. Hemostasis was
adequate and the patient was discharged on post-operative Day 13 after an uneventful recovery
without clinical evidence of thrombotic complication
DISCUSSION: Bivalirudin is eliminated via predominantly renal excretion and proteolytic cleavage. Very
often,patients sustain acute kidney injury during CPB, and in such situations, elimination of drugs such
as bivalirudin decreases and can lead to severe bleeding complications. Hemodialysis with high-flux
filter eliminates 45-69% of bivalirudin. This case is unusual as it emphasizes the significance of
understanding the pharmacokinetics of drugs with narrow therapeutic index of safety. Hemodialysis is
an important modality which can be utilized to control bivalirudin induced bleeding in such life
threatening situations.
454

OHIO POSTER FINALIST - CLINICAL VIGNETTE Yun Hui Lee, MD
The Death of a “Healthy” Mother and Wife
Yun Hui Lee, MD Second Author: Kim Jordan, MD
INTRODUCTION: INTRODUCTION: Hepatosplenic T-cell Lymphoma (HSTCL) is only 1 of 2 gamma-delta
T-cell lymphomas recognized by the World Health Organization (2008). HSTCL accounts for

OHIO POSTER FINALIST - CLINICAL VIGNETTE Maroun Matta, MD
Beryllium, The New Dust In The Wind.
Maroun Matta, MD, UHCMC ; Fadi Seif, MD, UHCMC ; Hugo Montenegro, MD, UHCMC
INTRODUCTION: In 2004, Henneberger estimated the number of workers in industries with airborne
beryllium exposure throughout the United States to 134 000. Beryllium is used not only in spacecraft
and electronics, but in a wide range of products that include bicycle frames, golf clubs, computers,
jewelry, and dental alloys. Currently, there is serious concern that the current exposure limit
established by OSHA is failing to protect workers from beryllium sensitization and chronic beryllium
disease (CBD).
CASE PRESENTATION: 60-year-old Caucasian female was admitted for a 2-week history of dyspnea on
exertion and a persistent dry cough. She denied fever, chills, night sweats, weight loss, orthopnea, and
lower extremity edema. Her past medical history was notable for a diagnosis of sarcoidosis since the age
of 20. She was treated with prednisone on multiple occasions. On examination, the patient’s vital signs
were within normal limits. Her oxygen saturation was 91% on room air. Lung exam showed bilateral
inspiratory and expiratory wheezing with poor air entry. Her CBC and blood chemistry, were normal.
Chest X-ray showed diffuse interstitial infiltrates, more pronounced in the upper lobes with bilateral
calcified lymph nodes. A high resolution chest CT showed a diffuse reticulonodular pattern with multiple
hilar subcentimetric nodules with calcification. Pulmonary-function testing showed a FVC of 2.08L, a
FEV1 of 1.24L and a ratio of FEV1 to FVC of 60% with normal lung volumes and a DLCO of
79%. Fiberoptic bronchoscopy with lung biopsy showed, non caseating granulomatous inflammation,
with no interstitial fibrosis and negative acid fast bacilli, or fungi. On further questioning, the patient
mentioned working for a year in a beryllium lab at the age of 16, sifting beryllium dust through a ten
mesh filter to make fine powder. Beryllium lymphocyte proliferation test (BeLPT) in the blood and
bronchoalveolar lavage (BAL) fluid was sent and was positive. The diagnosis of chronic beryllium disease
(CBD) was made.
DISCUSSION: CBD shares many clinical and histopathological features with pulmonary sarcoidosis.
Among patients diagnosed with sarcoidosis with confirmed beryllium exposure, as many as 40 percent
may actually have CBD. This case illustrates the value of a detailed exposure history and the use of
BeLPT in blood and BAL fluid to make the right diagnosis in patients who present with chronic dyspnea.
Identifying more patients with CBD may help develop more targeted treatment. Furthermore, BeLPT
can diagnose beryllium sensitization in asymptomatic individuals exposed to beryllium. These individuals
were proven to have a high likelihood of developing CBD, and may benefit from removal from exposure,
and close follow up to detect the disease at its earliest stage when treatment is most effective.
456

OHIO POSTER FINALIST - CLINICAL VIGNETTE Mustafa Musleh, MD
A Common Infection With An Unusual Organism Masquerading As A Mycobacterium
Mustafa Musleh, MD Co author: Richard K Groger
INTRODUCTION:We report the first case of severe catheter related blood stream infection (CRBSI) with
Tsukamurella species in an immunocompetent patient.
CASE PRESENTATION: An 85-year-old Caucasian female presented to the hospital from a nursing home
complaining of generalized weakness and shortness of breath. Her past medical history was significant
for coronary artery disease, hypertension, and a recent pulmonary embolism. She had a peripherally
inserted central venous catheter (PICC), placed during a recent hospitalization for acute stroke 20 days
prior to the current admission. The patient was hypotensive and tachycardic and responded to IV fluid
resuscitation. Initial lab studies were unremarkable, and a CT of the chest was negative for pneumonia.
Blood cultures showed gram positive bacilli. The patient was started on broad spectrum antibiotics
(doripenem and vancomycin). Microbiology lab subsequently reported rapidly growing mycobacteria.
Consequently, vancomycin was stopped and clarithromycin and moxifloxacin were started. The patient
did not respond to antibiotic treatment and repeat blood culture remained positive until the PICC line
was discontinued on the seventh hospital day. Due to inability to identify the pathogen, isolates were
sent to Focus Diagnostics laboratory for further identification. On the 16th hospital day the lab reported
Tsukamurella species, which was susceptible to all antibiotics tested including clarithromycin and
imipenem. During hospitalization the patient developed severe sepsis and multi-system organ failure.
On the 13th hospital day one blood culture grew Enterococcus faecium, and the patient eventually
expired on the 17th hospital day.
DISCUSSION: Tsukamurella species are strict aerobic gram-positive rods that are weakly acid-fast.
Although Tsukamurella infections are rare in humans, the species is probably under-reported when
commercially available testing is used. Isolates can be easily misidentified as Mycobacteria, Nocardia, or
Corynebacteria. Thirty-five cases reporting human infection with Tsukamurella were reported in the
literature. Fifteen cases were CRBSI, all of which occurred in immunocompromised patients with either
malignancies or chronic kidney disease on dialysis with long-term indwelling venous catheters. All
patients were successfully treated with antibiotics and catheter removal. Elimination of the catheter was
essential for eradication of the infection and a subsequent favorable outcome. Our patient is the first
CRBSI of Tsukamurella in a relatively immunocompetent patient. Other than possible
immunosenescence, our patient had no other cause for a compromised immune response. Unlike all
previously reported cases of similar infection, this patient had no history of malignancies or renal
disease and was not on immunosuppressive medication. While most previously reported cases with
Tsukamurella CRBSI survived after antibiotics and catheter removal, this patient did not. It is true that
infection with Tsukamurella may have not been the only cause for this patient’s death, but the infection
at least contributed to the eventual outcome.
457

OHIO POSTER FINALIST - CLINICAL VIGNETTE Chithra Poongkunran, MBBS
A Chilling Chance To Survive!Therapeutic Hypothermia
Chithra Poongkunran MD,Nihad Boutros MD, Rama Narayanan MD
INTRODUCTION: The use of Therapeutic hypothermia [TH] in comatose patients following near hanging
attempts to improve neurological outcome has been reported in few case series.There has been no
conclusive evidence in the literature regarding the benefits of TH in these situations. We report two
cases of complete neurological recovery with TH in survivors of near-hanging attempts.
CASE PRESENTATION:
458
CASE 1
A 55 year old male with no significant medical history was brought to the hospital after he was
found by his spouse hanging from an electrical cord in his garage. The estimated hanging time
was 5 minutes.In the ER, the patient was unresponsive with decerebrate posturing and was
intubated. His CT of the head and neck were normal. He was initiated on the hypothermia
protocol at 32 o C. He was sedated with propofol and cisatracurium was used to control shivering.
He was eventually extubated and the hypothermia protocol was discontinued after 24 hrs.
Patient improved remarkably with no neurological sequelae.
CASE 2
A 57 year old male with a significant history of depression and alcohol abuse was admitted to
the hospital after a near-hanging suicidal attempt with a belt in his garage. His estimated
hanging time was 10 minutes. He was unresponsive and had a pulseless electrical activity. CPR
was initiated with return of spontaneous circulation in 5 minutes. In the ER, he was intubated
and sedated with propofol. His CT head was negative but CT neck showed mildly displaced T1
and T2 transverse process fractures. The hypothermia protocol was started but was
discontinued in 12 hours due to severe bradycardia.The patient self extubated the next day and
had complete neurological recovery. He was transferred to psychiatric floor.
DISCUSSION: The induction of hypothermia to a target temperature 32 o C to 34ºC for 24 hours has
shown to improve the neurologic outcome of patients who remained comatose after cardiac arrest.
Studies suggesting similar benefits of TH after near hanging has also been reported but the literature
supporting it is very limited. In a recent study by Lee et al, the neurological outcome in near hanging
patient with cardiac arrest was poor despite TH treatment. A complete neurological recovery was seen
in both our patients with and without cardiac arrest. Though the positive outcomes in our patients is
reassuring,randomized controlled trials for an evidence based approach is much awaited. But in the
absence of conclusive evidence, it would be reasonable to consider TH in comatose near hanging
victims.

OHIO POSTER FINALIST - CLINICAL VIGNETTE William C Schnackel, MD
Exercise-associated Hyponatremia In A Weekend Warrior
William C Schnackel, MD Second Author: Kim Jordan, MD, FACP
INTRODUCTION: Exercise-associated hyponatremia (EAH) can occur in amateur and professional
athletes competing in endurance type events. Physiologic complications can be devastating, and include
seizure, coma, and death. The etiology of this electrolyte disturbance includes sodium loss through
diaphoresis, consumption of hypotonic fluids, and SIADH.
CASE PRESENTATION: A 43 year old male was hospitalized following seizure and cardiopulmonary
arrest which occurred during an extended bicycle race. He denied significant medical history and
medication use. The patient had cycled approximately 25 miles when he experienced muscle cramps
and felt ill. He stopped for fluid hydration when he had a witnessed seizure, lost pulse and experienced
respiratory failure. CPR and intubation occurred in the field and he was transported to an outside
hospital. Rhythm analysis was not recorded. Laboratory studies revealed hyponatremia 113 mEq/L and
hypokalemia 2.6 mEq/L. Normal saline 0.9% infusion was started and patient was transferred to our
hospital. Admission studies included serum sodium 113mEq/L, urine sodium 36, serum osmoles 248,
urine osmoles 519, and CPK of 4835 U/L. He was treated with 3% normal saline overnight and provided
supportive therapy. His CPK plateaued at 17,000 U/L, and baseline serum creatinine rose from
0.65mg/dL to 0.95mg/dL. By hospital day 5, the patient was extubated, creatinine level was improving
toward baseline, and serum sodium was normal.
DISCUSSION: The incidence of exercise-induced hyponatremia (EIH) varies by athlete demographic,
experience, training, and event. Reports estimate that between 2-7% of endurance athletes experience
mild hyponatremia with sodium levels

OHIO POSTER FINALIST - CLINICAL VIGNETTE Patrice Scipio, MD MPH
Defying Occam’s razor – dyspnea as a manifestation of renal disease.
Patrice Scipio, MD MPH Second Author: Michael Tuchfarber, MD
INTRODUCTION: Rapidly progressive glomerulonephritis (RPGN) is characterized by a rapid increase in
creatinine over a few days to months. While the histopathological diagnosis of RPGN is based on
glomerular crescent identification, the clinical diagnosis is less defined and constitutional symptoms
such as fatigue, anorexia and arthralgias, along with laboratory findings of hematuria, oliguria, and
proteinuria, may herald the onset of RPGN. Despite the non-specificity of clinical findings, early
diagnosis and treatment are important to prevent permanent kidney damage and thus death. The case
below describes pauci-immune necrotizing glomerulonephritis- a sub-type of rapidly progressive
glomerulonephritis- and a small vessel vasculitis that usually involves anti-neutrophil cytoplasmic
antibodies (ANCA). It emphasizes the ambiguity with which RPGN may present, especially in the face of
other chronic medical conditions and the need for a high clinical suspicion and aggressive treatment.
CASE PRESENTATION: An 84 year old female with a history of diastolic congestive heart failure,
chronic obstructive pulmonary disease, hypertension, coronary artery disease, generalized arthritis and
allergic rhinitis, was admitted to the hospital with a 3-week history of progressively worsening
dyspnea. Physical examination was significant for hypertension and bibasilar crackles without
peripheral edema. Chest X-ray was consistent with congestive heart failure (CHF). Echocardiogram
showed a normal left ventricular ejection fraction with impaired diastolic filling. Intravenous lasix and
breathing treatments were administered with minimal resolution of the patient’s dyspnea. Incidental
findings of normocytic anemia to 9.5, elevated creatinine to 3.3, proteinuria and hematuria pointed to
acute kidney injury as an indirect cause of the patient’s CHF. Diclofenac and losartan were discontinued
and per cardiology consult metoprolol and imdur were initiated for blood pressure control. Iron studies
revealed iron deficiency anemia with a reticulocyte index of 2.7. Hemoccult testing was negative.
Nephrology was consulted. Spot protein creatinine ratio and ESR were elevated. Haptoglobin was
within normal limits. Workup for multiple myeloma was grossly unremarkable. ANCA testing revealed a
positive myeloperoxidase with a negative proteinase-3. Renal ultrasound demonstrated bilaterally
increased renal echogenicity. Methylprednisolone and cyclophosphamide were initiated with continued
increase in creatinine to 6.1. Renal biopsy was performed and revealed pauci-immune rapidly
progressive glomerulonephritis. Dialysis was additionally initiated for uremia and after one dialysis
session, the patient’s creatinine decreased to 3.8 and she was discharged home with renal follow-up.
DISCUSSION: In this case, the patient’s symptoms of dyspnea could have been falsely attributed to
chronic obstructive pulmonary disease or congestive heart failure. A more comprehensive workup with
eventual renal biopsy revealed that pauci-immune necrotizing glomerulonephritis was in fact
contributory to her dyspneic symptoms. Furthermore the patient required aggressive combined
treatment with steroids, cyclophosphamide and hemodialysis.
460

OHIO POSTER FINALIST - CLINICAL VIGNETTE Raja K Singh, MBBS
Prostatic Abscess caused by community acquired Methicillin-resistant Staphylococcus Aureus.
Raja K Singh, MBBS MD, Ashwini Ammunje, MD, Rohit Mahajan,MD, Mushtaq Ashraf MD, Sneha
Koomori MD, Ricardo DeLeon MD.
INTRODUCTION: Community acquired Methicillin-resistant Staphylococcus Aureus (CA-MRSA) has
emerged as a significant pathogen in the recent years. Most MRSA infections are associated either with
hospitalized patients or skin/soft tissue infections. Here we report what we believe to be a rare prostatic
abscess secondary to community acquired MRSA in a healthy diabetic patient.
CASE PRESENTATION: Sixty four year old male with no prior history of physician visits or
hospitalization presented with one week duration of fatigue, malaise, mild abdominal distention and
urinary retention. He denied history of any cardiac, renal, urological or respiratory disorder. He was
diagnosed with new onset diabetes mellitus with glycosylated hemoglobin of 14.8 percent. A digital
rectal exam was not performed. Laboratory work up demonstrate white cell count (WBC) of 17,000/ cu
mm, prostate specific antigen of 8.51ug/L. His urine cultures were positive for more than 100,000 colony
forming units of MRSA. Two sets of blood cultures were positive for MRSA. He was started on
vancomycin. Computed Tomography (CT) showed pelvic fluid collection along the posterior margins of
prostate and loculated fluid collections within the prostatic fossa. Eight milliliters of purulent pus was
aspirated under CT guided drainage. Cultures from drained pus confirmed MRSA in prostatic abscess.
Subsequent trans-urethral resection of prostate and un-roofing confirmed the diagnosis. His white cell
count continued to decrease and he was discharged home with prolonged course of vancomycin.
DISCUSSION: Prostatic abscess with CA-MRSA is a previously healthy individual is a rare phenomenon.
To our knowledge there has been only two previous such case reports in world literature. Our patient
had none of the traditional risk factors for MRSA and would be classified by standard criteria as having
CA-MRSA. He did have newly diagnosed diabetes mellitus, which is a risk factor for prostatitis/prostatic
abscess. Our case reinforces the necessity for physicians to be diligent while evaluating and treating a
case of suspected prostatitis/prostatic abscess. The primary treatment of prostatic abscess should
always be drainage, along with appropriate antibiotics as directed by the cultures of the drainage. With
increasing incidence of CA-MRSA, clinicians should have a high index of suspicion to look for unusual foci
of infection such a prostate in previously healthy individuals.
461

OHIO POSTER FINALIST - CLINICAL VIGNETTE Brett C Sklaw, MD
Highly Probable, But Falsely Diagnosed
Brett C Sklaw, MD Second Author: John Davis, MD
INTRODUCTION:Pulmonary embolism (PE) is a disease process that often appears in the differential
diagnosis of patients with respiratory complaints. Unfortunately, it can be a challenging diagnosis to
make as V/Q scans are imprecise and CT pulmonary embolism studies have significant associated risks.
In patients with abnormal renal function, the previously mentioned complexities make this diagnosis
difficult.
CASE PRESENTATION: A 59 year old Senegalese male with a past medical history of end-stage renal
disease due to hypertension (formerly on hemodialysis), renal transplant two years prior, and DVT,
presented to another institution with pleuritic chest pain, cough, and dyspnea for one month. Evaluation
at the outside facility revealed acute renal failure and a high probability V/Q scan for PE. He was
transferred to our institution. On arrival, he was not in distress. He was afebrile with stable vital signs,
with an oxygen saturation of 97% on room air. His physical examination was remarkable for diminished
breath sounds over the left lung base. He arrived on a heparin drip. His immunosuppressant medications
included sirolimus and cyclosporine. A chest x-ray showed patchy left lung disease and interstitial
changes at the right lung base. A non-contrast chest CT showed bilateral cavitary pulmonary nodules.
He was ruled out for tuberculosis. CT guided biopsy revealed necrotizing granulomatous inflammation,
but no pathogenic organisms. There was no suggestion of PE. Wedge biopsy confirmed granulomatous
inflammation, with staining positive for Mycobacterium species. He was started on an anti-tuberculosis
regimen empirically. Following discharge, cultures demonstrated Mycobacterium avium complex (MAC)
and he was switched to an anti-MAC regimen. One month following discharge, he was reportedly doing
well.
DISCUSSION: The diagnosis of pulmonary embolism can be challenging in patients with abnormal renal
function because V/Q scans are imperfect and CT PE studies are contraindicated. This case illustrates
that complexity and reinforces the need to maintain a broad differential diagnosis, despite the presence
of strongly suggestive diagnostic testing, in order to avoid the error of premature closure. This is
particularly important in the immunocompromised host and other vulnerable patient populations.
Without appreciating the limitations of a high probability V/Q scan, the diagnosis in this case would
have been missed. Instead, by carrying out appropriately thorough diagnostic evaluation, including an
invasive wedge biopsy, the appropriate diagnosis was made, and mismanagement and further
complications were avoided
462

OHIO POSTER FINALIST - CLINICAL VIGNETTE Ryan Patrick Spilman, DO
RECURRENT ESOPHAGEAL STRICTURES? CONSIDER ESOPHAGEAL LICHEN PLANUS
Ryan Spilman, D.O. Additional Authors: Lisa Mewhort, M.D., Kim Jordan, M.D., FACP, Michael Taxier,
M.D. Riverside Methodist Hospital. Columbus, Ohio.
INTRODUCTION:It is well-known that systemic diseases, including connective tissue disorders and
infectious processes, can involve the esophagus. Esophageal lichen planus (ELP), however, is quite rare
with fewer than 50 previous case reports. Though uncommon, it is important that physicians recognize
the presentation of ELP so that proper therapy can be initiated given its association with significant
morbidity.
CASE PRESENTATION: A 60 year old female with a 25 year history of persistent dysphagia, despite H2
blocker and proton pump inhibitor therapy, presented for esophageal dilation. She had required annual
esophageal dilation over 20 years for recurrent strictures previously attributed to cervical esophageal
webs. Prior pathology was negative for significant abnormalities, including absence of eosinophilic
esophagitis. In 2009, she developed new oral lesions of the buccal mucosa and biopsy was consistent
with oral lichen planus. She later developed characteristic lesions on the dorsal surface of both hands;
both oral and cutaneous lesions improved with topical steroid therapy. Subsequent EGD revealed a
benign-appearing, severe stenosis in the upper third of the esophagus which was dilated and biopsied.
Pathologic examination found a lymphocytic infiltrate concentrated at the junction between the lamina
propria and overlying squamous epithelium and vacuolation of the squamous keratinocytes, consistent
with lichen planus. Civatte bodies (necrotic keratinocytes) were not noted, and findings of eosinophilic
and Barrett’s esophagitis were absent. A diagnosis of ELP was made based on pathology, concomitant
oral and skin lesions, and endoscopic findings. Oral fluticasone was started. She required one
subsequent dilation of the upper esophageal stricture one month later for recurrent symptoms. At that
time, facial lesions characteristic of lichen planus were present. She returned one year later for
surveillance, oral fluticasone had been discontinued, and she had developed a new stricture in the lower
esophagus.
DISCUSSION: Esophageal lichen planus (ELP) is an inflammatory papulosquamous disorder which
primarily affects middle-aged to older women. Most affected patients already have characteristic oral or
genital lesions, but cutaneous lesions are not always present. Patients commonly present with
dysphagia or odynophagia and mid or upper esophageal stricture, with friable mucosa is noted on
endoscopic examination. Pathological examination reveals epithelial detachment, dense lympocytic
infiltrate of the epidermis in a band pattern, and anucleated necrotic basal cells (Civatte bodies). Civatte
bodies, when present, are pathognomonic, but are present in only 40% of cases. Therapy centers on
topical and systemic immunosuppression. Left untreated, ELP may lead to stricture formation, and longstanding
disease may be associated with squamous cell cancer. Given significant associated morbidity, it
is important that physicians recognize ELP and initiate appropriate therapy.
463

OHIO POSTER FINALIST - CLINICAL VIGNETTE Swapna Thota, MD
Hemobilia and Arterioportal Fistula – A Rare Complication of Liver Biopsy
Swapna Thota, MD, Gaurav Kistangari, MD, Harris Taylor, MD
INTRODUCTION: Ovarian hyperstimulation syndrome (OHSS) occurs in approximately 25% of women
treated with injectable fertility medications. The vast majority of patients who develop OHSS will
experience mild, self-limited symptoms which resolve in about a week. Severe symptoms and
complications requiring hospitalization occur in only 1 to 5 percent of women. Recognition of signs and
symptoms and knowledge of pathophysiology of this syndrome are important for prompt
implementation of correct therapy as severe complications can result in serious morbidity or lifethreatening
disease.
CASE PRESENTATION: A healthy 41 year old female, gravida 1, para 0, underwent fertility treatment
with egg placement approximately one week prior to presentation. She presented to the emergency
department with abdominal distention, decreased urine output and a 15 kg weight increase over one
week. On examination, she was afebrile, with blood pressure 101/74 and heart rate of 95. Anasarca with
3+ pitting edema of the thighs was noted, but she had no lower leg edema. Abnormal laboratory studies
included a metabolic acidosis and hyponatremia of 126. BUN and creatinine were normal. Abdominal
ultrasound revealed large ascites, but no portal vein thrombosis. Grade III OHSS was diagnosed and
treatment initiated, including paracentesis of approximately three liters of fluid and aggressive
intravenous fluid resuscitation. All symptoms improved and patient was discharged after several days.
At one week followup, the patient had normal urine output, no ascites, and only trace edema of lower
extremities. Ultimately, she gave birth to fraternal twins at 33 weeks.
DISCUSSION: OHSS occurs due to marked ovarian enlargement from multiple ovarian cysts and acute
fluid shift out of the intravascular space, related to increased vascular permeability in the region
surrounding the ovaries and their vasculature. Risk factors for OHSS include polycystic ovary syndrome,
low body weight, young age, multiple gestation state, and prior history of OHSS. Rapidly rising estradiol
level and multiple oocytes on ultrasound are also predictors. This syndrome is classified as Grade I, II, or
III based on symptom severity and cyst size. Though most women experience only abdominal bloating,
mild abdominal pain, or weight gain (Grade I ), severe symptoms can occur including significant rapid
weight gain (more than 10 lbs in less than one week), ascites, renal failure, hypovolemic shock,
hypercoagulability, acute respiratory distress syndrome, and death (Grades II, III). Grade I OHSS is
generally self-limited and conservative care is appropriate; however, patients with moderate to severe
OHSS require hospitalization, aggressive fluid resuscitation, prophylactic heparin and analgesia.
Paracentesis may be necessary to improve venous return and renal perfusion. Surgical intervention may
be needed in extreme cases of ovarian torsion, rupture, or hemorrhage.
464

OHIO POSTER FINALIST - CLINICAL VIGNETTE Azadeh Toofaninejad, DO
EPIPLOIC APPENDAGITIS… A DIVERTICULAR DELUSION
Azadeh Toofaninejad, DO (Associate), Carl Ortman, MD (Associate), Kim Jordan, MD (Fellow)
INTRODUCTION: Epiploic appendagitis (EA) is an uncommon cause of acute abdomen in otherwise
healthy patients with mild or absent secondary signs of abdominal pathology. EA is frequently
misdiagnosed as either appendicitis or diverticulitis, which may lead to unnecessary hospitalization,
antibiotics or surgery. We report clinical and radiologic characteristics of two patients that were
diagnosed with EA.
CASE PRESENTATION: CASE 1: A 33 year old male with history of nephrolithiasis presented with left
flank pain, exacerbated by eating. He denied fever, nausea, vomiting and diarrhea. Examination revealed
normal vital signs, and slight tenderness in the left lower quadrant (LLQ) without rebound. CBC,
chemistries and urinalysis were normal. Abdominal and pelvic CT was initially reported as diverticulitis of
distal descending colon and ciprofloxacin and metronidazole were started. However, given patient’s lack
of fever, absence of leukocytosis, and his clinical presentation, the team asked for film review. A second
radiologist noted ovioid fat densities on CT characteristic of epiploic appendagitis. Antibiotics were
stopped, the patient was treated with pain medications, monitored overnight and discharged to home in
stable condition.
CASE 2: A healthy 26 year old male was admitted with four days of progressive stabbing LLQ pain. He
denied fever, and had been eating well with normal bowel movements. Physical examination revealed
normal temperature, blood pressure 140/103, pulse 100, and mild tenderness to palpation at LLQ. CBC,
chemistries, and urinalysis were normal. CT of the pelvis/abdomen was interpreted as acute
inflammatory changes at the junction of the descending and sigmoid colon consistent with acute
diverticulitis. However, given no clinical findings for acute diverticulitis, radiologist reviewed the images,
when he noted characteristic oval shaped areas of fat with surrounding inflammatory changes,
consistent with epiploic appendagitis. Patient was discharged to home on pain medications and was
instructed to follow up with PCP in one week.
DISCUSSION: Appendageal epiploicae are normal, fat-filled out-pouchings of peritoneum arising from
the serosal surface of the colon. EA is a benign, self-limiting cause of abdominal pain, more frequently
seen between the second and fifth decades of life, and induced by either appendageal torsion or
spontaneous venous thrombosis of an appendageal draining vein. In the past, EA was a diagnosis of
exclusion and was only confirmed after surgery. However, with improved imaging techniques, surgery
may be prevented. CT findings are virtually pathognomonic, revealing a 2-5 cm, oval-shaped, fat density,
paracolic mass with thickened peritoneal lining and surrounding fat stranding. When patients present
with localized lower abdominal pain and lack associated symptoms or laboratory abnormalities, epiploic
appendagitis should be highly suspected. Symptoms respond well to anti-inflammatory medications, and
generally last only a week.
465

OHIO POSTER FINALIST - CLINICAL VIGNETTE Bill C Tran, MD
Apical Hypertrophic Cardiomyopathy: Common Presentation of a Rare Disorder
Bill C Tran, MD Second Author: Bimal Padaliya, MD
INTRODUCTION: Apical hypertrophic cardiomyopathy (AHC), also known as Yamaguchi syndrome, is a
rare, benign subtype of hypertrophic cardiomyopathy (HCM) that affects approximately 25% of HCM
patients in the Japanese population and approximately 1-2% of HCM patients of non-Japanese
descent. Classically, asymptomatic patients are identified based on suggestive electrocardiographic
findings that include giant T wave inversions in the anterolateral precordial leads secondary to
repolarization abnormality. Diagnosis is confirmed by surface echocardiography or cardiovascular
magnetic resonance. In patients with typical chest pain presenting with similar ECG findings, initial
diagnostic work-up includes ruling out an acute coronary syndrome (ACS). The current case illustrates a
common presentation of a chest pain syndrome identified as a rare diagnosis of AHC.
CASE PRESENTATION: A 40-year old Caucasian male without significant past medical history presented
to the emergency department with several hours of acute onset substernal crescendo chest discomfort.
The discomfort radiated to his bilateral shoulders and was associated with nausea, flushing, and
lightheadedness. Patient denied any prior history of similar chest discomfort and his sole cardiovascular
risk factor included ongoing tobacco abuse. There was no family history of premature coronary artery
disease, sudden cardiac death or cardiomyopathy. Physical exam showed normal vital signs, no jugular
venous distention, a displaced apical impulse, a prominent fourth heart sound, clear lung fields and
warm lower extremities with no lower extremity edema. Chest x-ray showed no acute cardiopulmonary
process. ECG demonstrated sinus bradycardia, left ventricular hypertrophy with deep, symmetrical
anterolateral T wave inversions. Laboratories were significant for a mildly elevated troponin-I of 0.24
ng/ml (normal < 0.06 ng/ml). Patient was treated for a non-ST elevation myocardial infarction with
aspirin 325mg, clopidogrel 600mg, intravenous heparin, and sublingual nitroglycerin and transferred to
our institution for coronary angiography. Cardiac catheterization revealed angiographically normal
epicardial coronaries with left ventriculogram demonstrating normal wall motion and apical
hypertrophy. Surface echocardiography reaffirmed isolated hypertrophy in the left ventricular apex in
an “ace-of-spades” configuration. Patient was diagnosed with AHC and discharged home with
outpatient holter monitoring, follow-up genetic counseling, and recommended screening of first-degree
family members.
DISCUSSION: This case illustrates a rare diagnosis of AHC in a patient that presented with common
symptoms and findings mimicking ACS. The work-up for chest pain syndromes commonly includes a
broad differential diagnosis where a detailed history, physical exam, and focused noninvasive and
invasive testing can be diagnostic as highlighted by this case. Physicians who care for patients with
chest pain syndromes should therefore be aware of this rare subtype of HCM and the classic findings
associated with it.
466

OHIO POSTER FINALIST - CLINICAL VIGNETTE Amy Vizcarra, DO
PERSONALITY CHANGE IN AN 80 YEAR OLD: AN UNUSUAL CASE
Amy Vizcarra, DO Second Author: Kim Jordan, MD
INTRODUCTION: INTRODUCTION: Elderly patients are often diagnosed with dementia or delirium
when presenting with confusion, psychomotor agitation, complex paranoid delusions, and impaired
functional ability. These same symptoms also meet the DSMIV criteria for bipolar disorder. Because
initial presentation of manic disorder in the geriatric population is uncommon, patients may be misdiagnosed,
leading to inappropriate therapy, substantial morbidity and mortality.
CASE PRESENTATION: An 80-year old female with a family history of schizophrenia presented to an
outside hospital with confusion, agitation, slurred rapid speech, and “rambling ideas”. Physical
examination was normal, except for agitation, temporal disorientation, and delusions. Brain CT and MRI
were read as “chronic microvascular ischemic changes” with mild to moderate global
atrophy. Laboratory studies were normal. She was treated with haloperidol and released in 24 hours,
and was “ok initially” per family, except for insomnia and “nonstop talking”. Three months later, she
stalled her car in traffic, demonstrating bizarre behavior, resulting in police escort to the ER. Repeat
head CT was unchanged and evaluation for underlying medical illness was negative. She was admitted to
an inpatient psychiatric ward and diagnosed with bipolar disorder and mania. She improved with
ziprasidone therapy, but was discharged on no psychotropic medications. At follow-up, her primary care
physician started quetiapine for recurrent agitation, but she discontinued because of excess sedation.
She was subsequently referred to a geriatrician. Screening memory tests were normal (MMSE 30/30 and
3MS 98/100) but neuropsychological testing suggested mild frontal temporal deficits. Brain PET scan
showed mild decreased uptake in posterior cingulate, caudate, inferior frontal and superior temporal
gyri. TSH was mildly elevated at 6.24, and levothyroxine dosage was adjusted. Further historical review
revealed that she was diagnosed with hypomania and insomnia in 2005, though not treated. A trial of
valproic acid was initiated and at follow-up, her behaviors had improved and agitation decreased.
DISCUSSION: This case illustrates the challenges of recognizing clinical and historical features of bipolar
disorder (BD) in the geriatric population. New onset BD is uncommon after 65, with estimated
prevalence rates of 0.1-0.4%. In contrast to early BD, late-onset disease seems to be associated with
lower rates of familial illness, higher rates of medical and neurological comorbidity, and higher rates of
relapse. Clinically, elderly patients may demonstrate an increased incidence of frontal release signs, but
there are no path gnomonic findings. Neuropsychological tests may show diffuse cognitive dysfunction
and neuroimaging studies may reveal white matter hyperintensities, sulcal and ventricular enlargement,
or lateralization abnormalities on PET scan. “Best” treatment remains to be defined, but combination
therapy with an antidepressant, antipsychotic, and/or anti-seizure medication may be used.
467

OHIO POSTER FINALIST - CLINICAL VIGNETTE Zhenchao Wang, MD
Peripartum Cadiomyopathy: How Aggressive Anticoagulation should be to Prevent a Devastating
Stroke?
Zhenchao Wang, MD PhD; Sajid Farooq, MD; Sasan Raeissi, MD; Muhammad Rizwan Afzal, MD;
INTRODUCTION: Peripartum cardiomyopathy (PC) is a rare condition with increased incidence recent
years. The low incidence makes the diagnosis a challenging task. More importantly no sufficient data of
managing stroke associated with biventricular thrombi (BT), the serious complication of PC, makes
further studies for guideline of heparin treatment in this particular condition necessary.
CASE PRESENTATION: A 18-year-old African-American woman with history of childhood asthma
developed cough with white sputum and dyspnea on exertion on 32 weeks of pregnancy, which was
managed as pharyngitis in another facility. Two months after delivery on 38 weeks, she coughed up
blood tinged sputum. Echo was ordered this time which showed BT with LVEF 20-25%, she was
diagnosed PC. Weight-based heparin protocol was started with PTT ranging from 49-85 . After one day,
she developed generalized seizures with presentation of right hemiparesis two hours later when PTT
was maintain at 57.3. Stroke team was consulted at emergency and CT angiogram was ordered which
showed complete left internal carotid artery blockage with possible embolus or thrombus. tPA was not
initiated and clot retrieval was not successful. She was then given heparin infusion maintaining the PTT
at 78.8±8.8. By day 4 after the aggressive heparin infusion, she has no incidence of new stroke with
disappearance of thrombi and improved EF 25-30%. Pt was then bridged with warfarin and transferred
to rehabilitation program. Two month after, her EF improved to 35-40%.
DISCUSSION: Peripartum cardiomyopathy with increased incidence in recent years has been reported
associated with increased risk of BT, which can lead to devastating stroke. The awareness of this
condition is important. Also data are limited about management of BT. While weight based heparin
plays the major role in the resolution of the thrombi, the aggressiveness of heparin infusion remain to
be determined for prevention of major stroke. The case report above could be the initiative for further
studies of the management of BT in PC.
468

OHIO POSTER FINALIST - CLINICAL VIGNETTE Muhammad Ahsan Zafar, MD
CRYPTOCOCCAL MENINGITIS PRESENTING WITH ISCHEMIC STROKES IN A PREVIOUSLY UNDIAGNOSED
HIV PATIENT.
Muhammad Ahsan Zafar, MD Second Author: Lean Coberly, MD
INTRODUCTION: CASE PRESENTATION: A 44 year old homosexual male presented with unsteady
gait. He had recently lost his job and subsequently joined a rehabilitation program for severe depression
and functional decline. At presentation he lacked insight into his depressed functionality and
neurological deficits which had progressed over the preceding four months. He did report having a
tremor in his hands. On examination he had slow “parkinsonian” speech, masked facies, diffuse muscle
weakness, bradykinesia, generalized hyper-reflexia, ataxic gait and positive bilateral babinski reflexes.
There was no past or family history of strokes or other neurological pathologies. Head imaging showed
remote bilateral lacunar infarcts in the basal ganglia with two additional small foci of acute strokes in
the right basal ganglia. Traditional stroke workup was negative. A lumbar puncture revealed low glucose,
high proteins, high white count and numerous encapsulated yeasts. The CSF cryptococcal culture was
positive and the antigen level was elevated to 1:1,024. He was subsequently tested positive for HIV with
a CD4 cell count of 48/uL. Treatment was initiated with Ampohotericin and 5-Flurouracil followed by
Fluconazole. Six weeks after treatment the repeat CSF cultures were negative. Anti-retroviral therapy
(ART) was initiated after eight weeks. His functional deterioration had ceased, but the neurological
deficits persisted.
DISCUSSION: Ten to twenty percent of symptomatic HIV patients have neurological dysfunction,
though the prevalence of ischemic strokes is extremely low (

OKLAHOMA POSTER FINALIST - CLINICAL VIGNETTE Bhavin C Patel, MD
Pulmonary arterial hypertension: A clot in question.
Bhavin C Patel, MD* Other Authors: Aneesh Pakala MD*; Hany Magharyous MD**; Brent Brown MD†
*Department of Internal Medicine, † Section of Pulmonary and Critical Care, ** Department of
Pathology,
INTRODUCTION: Pulmonary Arterial Hypertension consists of a group of disorders characterized by
progressive increase in pulmonary vascular resistance leading to right heart failure and premature
death. Idiopathic pulmonary arterial hypertension (IPAH) is a diagnosis of exclusion, commonly
manifests as a progressive decrease in exercise tolerance and increasing dyspnea on exertion and carries
poor prognosis without treatment.
CASE PRESENTATION: A 63-year-old-man presented to the clinic with complaint of worsening dyspnea
on exertion (for 12 years) in 1999. Physical examination revealed an elevated jugular venous pressure,
bibasilar crackles, left parasternal heave, loud second heart sound, and bilateral pitting pedal
edema. Echocardiogram showed peak pulmonary arterial pressure (PAP) 77 mm Hg and normal LV
function. PFT showed restrictive pattern and normal diffusion capacity. High resolution CT scan of the
chest showed no evidence of interstitial lung disease. Heart catheterization showed a mean PAP 49 mm
Hg, peak PAP 77 mm Hg, LV end diastolic pressure 12 mm Hg. Pulmonary angiogram revealed a dilated
pulmonary trunk, significant pruning of the pulmonary vasculature, and no evidence of thrombi.
The patient was diagnosed with Idiopathic Pulmonary Hypertension (IPAH) and started on Epoprostenol
with doses escalating every 6-week for the duration of his life. Patient was also started on Warfarin,
which was discontinued for last 18 month because of recurrent GI bleed. The patient eventually
deteriorated and died after 17 years from initial diagnosis. Autopsy revealed the surprising finding of
extensive organized intramural thrombi involving the markedly enlarged pulmonary artery, usually seen
in patients with chronic thromboembolic pulmonary hypertension (CTEPH).
DISCUSSION: IPAH is rare disorder and a diagnosis of exclusion. In our case CTEPH was initially ruled
out by a pulmonary angiogram, however, on autopsy we were surprised to find extensive central
intramural thrombi generally consistent with a diagnosis of CTEPH. He had no clinical evidence of
Venous Thrombo-embolism in life or at autopsy. Although Small vessel in-situ thrombosis is a wellknown
pathologic finding in IPAH there are very few case reports of extensive thrombosis involving
central pulmonary artery in IPAH. We speculate he developed “in-situ” thrombi of main pulmonary
arteries, which contributed to worsened right heart failure and death. Patient with IPAH has several
mechanisms favoring thrombosis including decreased level of PGI2, Nitric oxide, thombomodulin and
increased level of thromboxane A2 and plasminogen activator inhibitor type 1. It is unknown if central
thrombi seen in IPAH are “in-situ” or embolic in origin but previously published case reports and
prothrombotic state in patient with IPAH favors our view. We emphasize importance on anticoagulation
in patient with IPAH and periodic screening with CT or MR angiography to look for central pulmonary
thrombi in patient who can not be anticoagulated. Clinician should keep heightened suspicion for
central thrombi leading to deterioration of clinical status in patient with IPAH.
470

OREGON POSTER FINALIST - CLINICAL VIGNETTE Kate S Gustafson, MD
A Puzzling Case of Acute Headache
Kate S. Gustafson, MD Alan J. Hunter, MD
INTRODUCTION: CASE PRESENTATION: 27 year old female with past medical history significant for
bipolar disorder, childhood seizure disorder and recent episode of thrush presenting with three weeks
of severe headache described as sudden in onset, constant, 10/10 throbbing pain associated with
nausea, vomiting, stiff neck, weight loss, photo- and phonophobia. Other history was notable for recent
bat exposure. She was hemodynamically stable at the time of admission and physical exam was
significant for the absence of meningeal signs and rash as well as a normal neurologic exam. Labs were
normal with exception of CSF with 7 WBC and a lymphocytic predominance (91%). MRI was decidedly
abnormal with dural based nodular and rim enhancement in bilateral frontal lobes along the superior
sagital sinus. Initial differential diagnosis included sarcoidosis, tuberculosis, autoimmune related
granuloma, granulomatosis polyangiitis, HIV-related opportunistic infection, fungal infection and
lymphoma. Extensive lab work-up returned primarily negative. With ongoing concern for possible
malignancy, a brain biopsy was performed. Despite the fact that the Steiner stain on the brain tissue was
negative for spirochetes, serum RPR returned at 1:8 and VDRL of the CSF was weakly positive. The
diagnosis of cerebral syphilitic gummata was confirmed with positive FTA-Ab and 16S ribosomal RNA
PCR that returned positive for T. pallidum in the brain tissue. Of note, the patient reported having a
single male partner with regular condom use. She was started on a continuous infusion of penicillin G 18
million units daily and had very rapid resolution of clinical symptoms.
DISCUSSION: Syphilis rates have been on the rise for much of the past decade, particularly in MSM. It is
an easily treatable disease in the early stages, but as it is known as one of the “great masqueraders” it is
a diagnosis that should be considered even if a patient does not seem to be at high risk based on history.
The most direct means of identification is dark field microscopy but serologies are much more
commonly used for diagnosis. There are both non-treponemal (i.e., RPR and VDRL) as well as
treponemal (i.e., FTA-Ab) tests. It is important to remember that approximately 30% of patients with
primary, latent and tertiary disease will have a negative non-treponemal test and that FTA-Ab remains
positive life-long. Fortunately, syphilis rates in the US declined slightly in 2010 for the first time since
2001
471

OREGON POSTER FINALIST - CLINICAL VIGNETTE Kristina L Bajema, MD
Acute Intermittent Porphyria: Regression Of Hallucinations And Neuropathy With Hemin
Kristina L Bajema, MD and Brinton Clark, MD
INTRODUCTION:Acute intermittent porphyria (AIP) is an inherited metabolic disorder of the heme
biosynthetic pathway that is characterized by a deficiency in porphobilinogen deaminase. During acute
attacks, individuals commonly experience symptoms of autonomic dysfunction including abdominal
pain, tachycardia, hypertension, and constipation. In some instances, attacks may be characterized by
peripheral neuropathy and encephalopathy. While hemin has been used to treat AIP flares, there are
currently no randomized trials to offer guidance on the benefit of this drug for porphyric neuropathy.
CASE PRESENTATION: A 52 year old man presented with episodic hallucinations and motor weakness
with rapid progression over the course of one month. On several occasions he experienced notable
confusion ranging from word-finding difficulty to complete disorientation, agitation, and visual
disturbances described as “patterns floating on the wall.” Moreover, he developed marked weakness
that left him unable to walk or lift his arms off the bed. He had a history of episodic diffuse abdominal
and musculoskeletal pain. His exam was notable for tachycardia, variable hypertension, cachexia,
dysphonia, and motor weakness most prominent in the proximal upper extremities with 1-2/5 strength
in the bilateral deltoids, wrist extensors and flexors and 2/5 strength in the intrinsic muscles of the
hands. Sensation was preserved. Labs were remarkable for elevated random urine porphobilinogen
(PBG) peaking at 321 umol/L (normal range 0-8.8umol/L) and random urine delta-aminolevulinic acid
(ALA) of 259 umol/L (normal range 0-35umol/L). The patient was treated with repeated infusions of
dextrose as well as two four day courses of hemin. With initial hemin treatment, the patient’s
encephalopathy and hallucinations resolved within 2-3 days and he demonstrated subtle improvement
in his upper extremity strength over the course of weeks. After discharge to a care facility, poor oral
intake resulted in a recurrence of his hallucinations and worsening weakness which again improved with
hemin.
DISCUSSION: Case studies have described a pattern of elevated urine PBG and ALA levels along with
abnormalities in nerve conduction studies correlating with symptomatic neuropathic attacks in patients
with AIP. Several hypotheses regarding the pathogenesis of neurological sequelae have been
proposed. First, heme deficiency leads to impairment of mitochondrial electron transport resulting in
neural energy deficits. Furthermore ALA, which can cross blood-nerve and blood-brain barriers, is
directly neurotoxic. In case reports, treatment with repeated hemin infusions has demonstrated gradual
improvement in motor weakness as well as a decline of porphyrin precursor levels and normalization of
electrophysiologic studies.
472

OREGON POSTER FINALIST - CLINICAL VIGNETTE Christopher A March, MD
Fungal coronary embolism: a rare cause of STEMI
Christopher A March, MD
INTRODUCTION:Coronary artery embolism is a rare but well-described phenomenon complicating
acute bacterial endocarditis. Invasive fungal infection is becoming more common as a cause of
endocarditis. Despite increasing prevalence, only one case report of fungal coronary embolism
complicating endocarditis could be found on PubMed query. The following is a case of this unexpected
complication of fungal endocarditis.
CASE PRESENTATION: ER is a 69-year old male with mechanical aortic valve and recent history of
treated Pseudomonas endocarditis admitted for evaluation after three surveillance blood cultures
revealed Candida parapsilosis infection. He was asymptomatic on admission and a colonoscopy was
planned to evaluate for a possible enteral source of fungemia. On hospital day #1, he suffered cardiac
arrest secondary to ventricular fibrillation. A pulse was regained after nineteen minutes of ACLS and he
was transferred to the ICU. Electrocardiography showed marked (>10mm) ST segment elevation in the
leads V2-V6; a pre-admission EKG did not show any ST segment abnormalities. The patient rapidly
developed signs of cardiogenic shock including hypotension, poor peripheral perfusion and both
significantly elevated CVP (>20 mmHg) and pulmonary capillary wedge pressure (27
mmHg). Echocardiography revealed decreased ejection fraction and akinesis of the apical and lateral
segments of the left ventricle. Cardiology was consulted and coronary angiography was deferred as fully
normal angiography was obtained within three months of the current admission.
The patient’s clinical condition continued to worsen despite dobutamine and ventilatory support. Left
coronary angiography was then obtained and displayed complete occlusion of the left anterior
descending (LAD) artery at the origin of the first diagonal artery by a mobile, “grape-like” collection of
emboli. Embolectomy was successful in restoring TIMI III flow to the distal LAD. Shortly after
embolectomy, shock physiology and ventilatory needs improved rapidly and the patient was successfully
extubated and transferred out of the ICU. Blood cultures continued to be positive for C. parapsilosis for
five days after embolectomy and antifungal medications were continued. Aortic valve replacement is
planned for definitive management of fungal endocarditis after rehabilitation from this acute illness.
DISCUSSION: Coronary embolism is a common complication of endocarditis, affecting up to 60% of
endocarditis cases on autopsy study. As described in this case, embolectomy is successful therapy for
coronary embolism; it specifically avoids the risk of prolonged anti-platelet therapy of stent placement
in a patient who may need urgent valve surgery. Risk factors for development of fungal endocarditis
include prosthetic valves, indwelling catheters and previous episodes of endocarditis. Angiography was
initially deferred in this case of STEMI due to the presumed lack of coronary artery disease from
previous angiography. As the incidence of fungal endocarditis increases, so should the vigilance for this
life-threatening complication.
473

OREGON POSTER FINALIST - CLINICAL VIGNETTE Jesus A Moreno, MD
Angioedema: a Life-threatening Presentation of Systemic Lupus Erythematosus (SLE)
Jesus A Moreno, MD
INTRODUCTION:
474
INTRODUCTION: The diagnosis of SLE, “the great imitator,” is challenged by its varied
presentation and clinical course.
CASE PRESENTATION: A previously healthy 18 year old Iranian man presented to the emergency
department with acute tongue and lip swelling that had rapidly progressed over 1 hour. Due to airway
compromise, he was treated with IV steroids and underwent emergent nasal intubation. The patient’s
family reported night sweats 3 months prior to admission, 1 month of fatigue, 2 episodes of subjective
fever, and 1 day of a mildly pruritic rash on his back. He moved from Iran at age 9 and had no recent
medication or travel exposures. Exam was notable for a markedly edematous purple tongue that
protruded beyond the teeth and no other skin findings. The patient’s angioedema resolved with
steroids and he was extubated. Extensive evaluation for an etiology of his profound angioedema
revealed a positive ANA, mild normocytic anemia, and ESR 56. Coagulation studies, complement, antidsDNA,
anti-ssDNA, ANCA antibodies, and serum creatinine were normal.
Outpatient follow up with rheumatology and hematology at 6 weeks revealed abnormal mixing
study, positive anticardiolipin antibody IgG, low C4 and C3 levels, and high C1Q at 122%. He was
diagnosed with hypocomplementemic urticarial vasculitis syndrome (HUVS). One year later he
presented with less severe tongue and facial swelling as well as malar rash and pancytopenia;
repeat laboratories revealed a positive anti-dsDNA. He was diagnosed with SLE and treated with
corticosteroids. His clinical course remains complicated with a recent hospital admission for
upper extremity vasculitis after non-adherence with steroid treatment.
DISCUSSION: This is a unique presentation of a young male with angioedema as his initial symptom of
SLE. SLE is a chronic inflammatory condition that affects multiple organ systems with a highly variable
clinical course. Although kinin-related angioedema due to abnormalities in complement is a known
association with SLE, it is a very unusual presenting symptom. Our patient met only 1 (positive ANA) of
the American College of Rheumatology criteria for diagnosis of SLE (i.e. malar rash, discoid rash,
photosensitivity, oral ulcers, arthritis, serositis, specific renal and neurologic disorders, hemolytic
anemia, pancytopenia, anti-dsDNA, antiSm, anti-phosphlipid antibodies or antinuclear antibodies),
whereas a minimum of 4 criteria define a clinical case. Underdiagnosis has been a criticism of these
criteria, which are more specific (95%) than sensitive (75%). Our case demonstrates the need for
ongoing surveillance of new symptoms and repeat laboratory testing in cases of undifferentiated
connective tissue disease as typical antibodies and physical findings may not be initially present.

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Sara Hanna, MBBCH
A case report of pituitary metastasis in a Breast cancer patient
By: Sara Hanna, MD, Peter Sidarous, MD, Pramil Cheriyath, MD, Leah Cream, MD
INTRODUCTION: Metastasis to the pituitary gland is very rare. Most common tumors that metastasize
to the pituitary are breast and lung cancer. We report a case of pituitary metastasis following breast
cancer treatment with symptoms of Central Diabetes Insipidus.
CASE PRESENTATION: This is a 53 year old female with a past medical history of HER2 positive
hormone negative inflammatory carcinoma of the left breast who presented with a 10 day history of
increased fatigue, thirst and polyuria. Patient was diagnosed with breast cancer two years ago and
received neoadjuvant chemotherapy in the form of Docetaxel, Carboplatin and Trastuzumab. She then
underwent bilateral mastectomy which revealed a residual tumor of 0.6cm with negative lymph nodes.
Postmastectomy radiation was also completed.
For four months, the patient has been regularly seen by her physicians for multiple different complains
such as anxiety, fatigue, decrease level of energy, increase thirst up to 15 glasses of water per day, body
aches, trouble in recalling people name and polyuria. Initial labs were within normal limit except for TSH
and free T4 that were in the lower range of normal. Patient was referred to endocrinologist who
diagnosed her with Central Diabetes Insipidus. On further investigations, serum cortisol was low
indicating secondary hypoadrenalism and hypothyroidism. Patient was started on Desmopressin,
resulting in great diminution of her polyuria and polydipsia. Patient was treated with Hydrocortisone
and Levothyroxine simultaneously. MRI of the brain showed a round enhancing mass lesion along the
inferior aspect of the infundibulum of the pituitary which was concerning for metastasis. Patient was
then referred to a neurosurgeon who removed the tumor through transphenoidal access and the biopsy
indicated metastatic breast cancer.
DISCUSSION: Brain metastases are the most common intracranial neoplasm and occur in about 25% of
all cancer patients. However, pituitary metastasis is rare accounting to 1 to 3.6% of patients with
malignant tumors, most commonly breast cancer. HER-2 positivity is an increasingly recognized risk
factor for the development of brain metastases. Only 7% of pituitary metastasis is symptomatic, mostly
involving the posterior pituitary. Even subtle symptoms should not be ignored in patients recently
diagnosed with cancer. Due to the rarity of this tumor, no study has been done to compare the success
of surgery in comparison to radiation or chemotherapy. One should focus on improving quality of life
but no survival benefit to any treatment modality has been proven.
475

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Anna Kaminsky, DO
Kaposi’s sarcoma
Anna Kaminsky, DO
INTRODUCTION: Kaposi’s sarcoma is a type of malignancy that is associated with immunosuppression,
such as HIV/AIDS, or in post-transplant patients, and is rarely seen in non-HIV population. No definitive
cure has been established, and conventional therapies such as chemotherapy and radiation carry high
toxicity risk, especially in elderly population with multiple comorbidities. Use of anti-viral medications
such as Valcyte and monitoring HHV 8 titers as a measure of response could be a better option in this
population.
CASE PRESENTATION: A 77-year-old female with a history of coronary artery disease, myocardial
infarction, hypertension, hyperlipidemia, and diabetes, presented with complaint of rash involving
multiple parts of her body. Physical exam showed multiple red colored lesions with irregular borders on
anterior right chest wall, right breast, left flank and left lateral trunk. Biopsy was performed and
confirmed diagnosis of Kaposi’s sarcoma. Workup revealed that she had negative HIV status. The PCR for
HHV 8 virus was ordered and came back positive with 49651 DNA copies/mL. She was then started on
Valcyte 1 g bid. She had regular office follow up and had excellent response with flattening and
disappearance of the lesions and decreasing adenopathy in chest, axillae and abdomen on a CT scan.
Follow up HHV 8 titers progressively decreased to 300 DNA copies/mL.
DISCUSSION: Traditionally, Kaposi’s sarcoma in non-HIV patient had limited treatment options with
significant side effects.This case illustrates that in elderly population with multiple comorbidities,
treatment with antiviral medications such as Valcyte results in an excellent response with minimal side
effects and prevents or delays more aggressive treatments such as chemotherapy. Monitoring HHV 8
titers was demonstrated to be a good measure of response correlating with clinical improvement
476

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aurangzeb Baber, MD
A Life Threatening Case of Aripiprazole Induced Dysphagia.
Aurangzeb Baber, MD. Second Author: Rizwan Tariq, MD.
INTRODUCTION: Dysphagia is a rare manifestation of Extrapyramidal symptoms, seen in patients
taking antipsychotic medication. The mechanism involves spastic paralysis of voluntary muscles used in
swallowing. To our knowledge this is the first ever reported case of dysphagia experienced in patient on
low dose aripiprazole.
CASE PRESENTATION: A 43 year old female with past medical history of depression, anxiety and mitral
valve prolapse, recently started on 1 mg of aripiprazole and titrated up to 10 mg to augment her
antidepressant medications, presented to the ER for evaluation of progressive dysphagia for the past 2
weeks. Her dysphagia had progressed to a point where she was not able to swallow her own saliva. A
stat upper GI endoscopy performed in the ER for concern of foreign body showed no gross abnormality.
She was admitted to general medical floor and made NPO. Psychiatry was consulted as the top
differential diagnoses were conversion disorder and medication side affect. Aripiprazole was held at this
point. Her swallowing function failed to improve over the course of next 4 days both subjectively and
through objective evaluation of speech pathologist. In the meanwhile she had to be transferred to ICU
for worsening non gap acidosis and hypotension attributed to starvation ketosis. At this point neurology
was consulted and patient was found to have Parkinson like features on neuro exam including mask-like
facies and cogwheel rigidity. She was started on diphenhydramine to treat the dystonic reaction. She
was also started on bicarbonate infusion and nasoenteral tube feeds. Her acidosis resolved and she was
transferred out of the ICU. A video barium swallow was done, which showed moderate oral and severe
pharyngeal impairment of swallowing function. Over the course of next week after being transferred
from ICU to general medical floor she felt that her swallowing function was getting better. A repeat
evaluation was done by speech pathologist showing significant improvement. A repeat video barium
swallow showed improvement from the prior study. She was started on a modified chopped diet and
she tolerated it well. She was discharged home on diphenhydramine, off aripiprazole and on a modified
chopped diet after 2 weeks of hospital stay.
DISCUSSION: This case illustrates the possibility of extremely rare side effect of aripiprazole, clinicians
must be aware of the possibility and consider early discontinuation of the medication if dysphagia
develops. Patients taking aripiprazole should be educated about the side effect, which should be
reported immediately.
477

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aurangzeb Baber, MD
Epstein Barr virus Induced Severe Hepatic Failure.
Aurangzeb Baber, MD. Second Author: Yassir Nawaz, MD.
INTRODUCTION:Epstein Barr virus(EBV) is a DNA virus associated with a benign self limited illness,
infectious mononucleosis. Infection in immunocompromised patients is sometimes severe and can lead
to fulminant hepatic failure. This is a case of a young immunocompetent female presenting with EBV
infection leading to severe acute hepatic failure.
CASE PRESENTATION: 18 year old female with past medical history of seizures presented to ER for
evaluation of fever, dysphagia and rash. She returned from a trip to North Carolina 1 week back and
developed facial swelling, fatigue and fever. She went to her pediatrician who did a rapid strep test
which was negative, and a monospot test which turned out to be positive. She stayed home
continued oral intake and took ibuprofen as needed. Her symptoms continued to get worse with
dysphagia, dysphonia, continued fevers, sore throat, lethargy and malaise. In the ER she was
hypotensive, febrile and had a diffuse rash. The rash was erythematous, macular and involved the palms
and soles. She had facial swelling and enlarged necrotic tonsils. Her labs showed elevated white count of
13.8 with 17% bands and 9% atypical lymphocytes. Her AST and ALT were almost twice the reference
range, bilirubin was 7.5 mg/dl and INR was 2.5. She was started on vancomycin, cefepime and
clindamycin. She was seen by infectious disease consultant next morning and doxycycline was added to
regimen for concern of Rocky Mountain spotted fever given recent travel to North Carolina and a rash.
Symptomatically she got better with the antibiotic treatment and IV hydration but her INR continued to
trend up and 24 hours after admission it went from 2.5 to 4.2. Her AST, ALT and bilirubin remained
elevated. Her blood, urine and sputum cultures were negative. Serologies for Hepatitis A, B, C and E
were negative. It was concluded that she has acute liver failure from EBV infection. She was evaluated
by gastroenterology and was transferred to a transplant facility for worsening numbers and concern for
fulminant hepatic failure although she did not have any hepatic encephalopathy at time of transfer.
DISCUSSION: A review of the literature reveals that EBV hepatitis is self limiting in most of the cases.
This case describes the potential of severe hepatic dysfunction in EBV infection even in healthy
immunocompetent individuals. Mortality and morbidity could be reduced by anticipating severe
infections, closely following the numbers and referral to transplant center in advance. This case is
unique as the Icteric presentations such as our patient are extremely rare
478

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Swapna Reddy
Bemalgi, MD
ACUTE BACTERIAL ENDOCARDITIS ASSOCIATED WITH GENITAL PIERCING
Swapna Reddy Bemalgi, MD Co- Authors: Parul Kaushik , Rizwan Tariq, Manuel Rosenberg ,Joseph
Hassey.
INTRODUCTION: INTRODUCTION: Streptococcus pyogenes is a very rare cause of acute infective
endocarditis with only a handful of cases reported in the literature. We believe this to be the first case
of group A streptococcus bacteremia and endocarditis associated with genital piercing.
CASE PRESENTATION: CASE DESCRIPTION: A 25-year-old man was admitted with fever, dysuria, yellow
penile discharge and left flank pain of one-day duration. Patient was seen in the ER ten days ago with
dysuria and penile discharge, when he received one dose of IM ceftriaxone and was discharged with
one-week course of doxycycline. His symptoms improved but recurred 2 days after he finished
doxycycline. History was significant for an uncomplicated Prince Albert piercing of his genitalia done 8
years ago. On admission, patient had a fever of 104 º F. Physical-exam revealed left flank tenderness and
a penile ring passing from the inferior aspect of glans through the urethra. There was no redness,
swelling or tenderness at the site of the ring or urethra. Laboratory results were significant for
leucocytosis with 17 % bands. He was started on IV vancomycin and ceftriaxone. Urine DNA probes for
Chlamydia and Gonococcus were negative and urine culture from 10 days ago grew Streptococcus
pyogenes. Two sets of blood culture on admission grew Streptococcus pyogenes and antibiotics were
appropriately de-escalated. Patient removed his penile ring. Despite appropriate antibiotics, he
continued to have temperature spikes with negative cultures. On hospital day 4, he complained of
painful lesions on palms and was found to have osler nodes on the fingers. On further exam, he was
found to have new subungal splinter hemorrhages, petechiae on his soles and a new diastolic-murmur in
the aortic area. Trans Thoracic Echocardiogram showed moderate sized vegetation on aortic valve
associated with severe aortic regurgitation. Repeat CT-scan of abdomen and pelvis with contrast
showed a wedge shaped left renal infarct. On hospital day-8, he underwent aortic-valve replacement
surgery. An intra-operative Trans Esophageal Echocardiogram showed 3mm perforation in the right
coronary leaflet of aortic-valve. The pathology of resected valve was consistent with infection. Postoperative
course was uneventful and he was discharged with a 4 weeks course of penicillin G.
DISCUSSION: DISCUSSION: Beta-hemolytic streptococcus are an uncommon cause of endocarditis
with a reported incidence of 0-5% in most reviews. Group-A streptococcus is usually the pathogen in
most of these cases and it can cause bacteremia, in association with acute pharyngitis, cellulitis ,
necrotizing fasciitis or intravenous drug use ,however it has not been reported with urethritis and
genital piercing. Streptococcus pyogenes are exquisitely sensitive to penicillins and they remain the drug
of choice in such infections.
479

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Monodeep Biswas,
MD
Spontaneous coronary artery dissection presenting as acute ischemic stroke - unusual presentation of
a rare condition
Monodeep Biswas, MD, Arjinder Sethi, Nimesh Patel, Anil Singh, Stephen J. Voyce
INTRODUCTION:Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary
syndrome or sudden cardiac death. SCAD presenting as acute, cardio-embolic ischemic stroke without
cardiac symptoms is extremely rare.
CASE PRESENTATION: A 26 year old Caucasian male presented with sudden onset left-sided weakness
associated with slurring of speech and a left facial droop. Past history was significant for an episode of
deep venous thrombosis occurring about one year ago. Hypercoagulable screen, including protein C and
S levels, factor V Leiden, antithrombin III, homocysteine levels, antiphospholipid and anticardiolipin
antibodies, was negative. The patient appeared in no acute distress. Vital signs showed a heart rate of
81 and a BP of 136/70 mm Hg. Cardiac examination revealed normal heart sounds. Lungs were clear.
Neurologic examination revealed left sided facial weakness with mild motor weakness and diminished
touch and pain sensations on the left side of his body. Deep tendon reflexes were brisk and the left
Babinski sign was positive. The admission EKG showed normal sinus rhythm, left anterior fascicular block
and age indeterminate anterior and inferior wall infarcts. Serial troponin I levels, were 0.02, 0.4, 0.31
ng/ml (normal < 0.05 ng/ml, indeterminate 0.06 - 0.5 ng/ml, positive > 0.5 ng/ml). MRI of brain
demonstrated a recent cerebral infarction in right middle cerebral artery territory. The patient was given
tissue plasminogen activator for stroke. A transthoracic 2D echocardiogram on admission demonstrated
regional wall motion abnormality over the apical portion of interventricular septum associated with an
apical mural thrombus. The ejection fraction was calculated at 46%. Coronary angiography showed a
radiolucent linear defect suggestive of an intimal dissection involving the mid to distal segment of the
left anterior descending artery with good flow. The patient was maintained on medical management,
including warfarin therapy, aspirin, beta-blocker and statin with outpatient follow-up.
DISCUSSION: SCAD has been reported most commonly in women during the peripartum period. It may
be associated with autoimmune and collagen vascular diseases, Marfan’s syndrome, chest trauma, and
intense physical exercise. No predisposing conditions could be identified in the patient. The pathology of
SCAD shows a dissection between the media and the adventitia of the artery due to cystic medial
necrosis or hemorrhagic disruption of the vasa vasorum. The common presentation of SCAD is acute
onset of severe chest pain associated with autonomic symptoms such as diaphoresis, palpitations and
either hyper or hypotension. Asymptomatic cases are rare. Percutaneous coronary strategies even
surgical revascularization is reasonable in acute cases with proximal dissection and arterial occlusion in
order to restore coronary perfusion and hemodynamic stability.
480

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Monodeep Biswas,
MD
Multiple vessel coronary artery occlusion- Common pathology with different presentation and
outcomes.
Monodeep Biswas, MD, Arjinder Sethi, Nimesh Patel, Anil Singh, Stephen J. Voyce
INTRODUCTION: Multi-vessel coronary artery occlusion is a rare and often fatal condition that
presents in a patient with multiple risk factors usually with cardiogenic shock. Here we describe two
cases with different modes of presentation as well as outcome.
CASE PRESENTATION: Case 1- A 52 year old white male with diabetes mellitus, hypertension,
hyperlipidemia, chronic renal insufficiency with history of anterior wall myocardial infarction with
coronary stents came with complaints of severe chest pain following an argument with one of his family
members. He went into ventricular fibrillation and had to be resuscitated and brought to the ER. He was
unresponsive and paralyzed. The patient was in shock with BP of 85/55 and feeble pulses. The EKG
showed sinus bradycardia, left posterior hemiblock and inferoposterior wall myocardial infarction. 2D
echocardiogram showed an ejection fraction of 40 %. The lateral and inferolateral wall was severely
hypokinetic. The coronary angiogram showed complete proximal occlusion of right coronary and left
circumflex marginal by large thrombus. Drug eluting stents (DES) were placed in these blood vessels. An
intraaortic balloon pump was introduced for hemodynamic support and patient was transferred to ICU.
The patient had hypoxic ischemic encephalopathy and had to be terminally weaned.
Case 2: A 66 year old obese, hypertensive white male came in to the ER with complaints of severe
retrosternal chest pain with radiation to the arms and along with diaphoresis and progressively
increasing shortness of breath lasting about an hour. BP was 85/60 at presentation. Clinical examination
was unremarkable. EKG showed marked ST segment elevation in all anterior leads consistent with acute
anterior wall myocardial infarction. Troponin I trended to a maximum value of 21.65 (positive is > 0.5).
Coronary angiogram showed total occlusion of left anterior descending artery after first diagonal and
left circumflex marginal artery with acute thrombus and DES were deployed appropriately with good
flow in the arteries. The patient had an uneventful recovery.
DISCUSSION: Multivessel coronary thrombosis is a rare clinical diagnosis in setting of acute coronary
syndrome. Due to occlusion of two or more epicardial coronary vessels a larger area of myocardium is
at-risk and patients are more likely to present with hemodynamic compromise or with sudden cardiac
death. Previous history of myocardial infarction (MI), family history of early MI, tobacco use and
presence of multiple coronary risk-factors are associated with multi-vessel coronary thrombosis.
Cocaine use or prolonged coronary vasospasm has been thought of as a potential cause too.
Hypercoagulable states related to cancer, hyperhomocysteinaemia, essential thrombocytosis, hormone
therapy and HIV infection has been reported as cause of multi-vessel coronary artery thrombosis.
481

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jincy Clement, MD
Acquired Hemophagocytic Lymphohistiocytosis Secondary to Severe EBV Infection In An Adult With
Common Variable Immune Deficiency: A Description Of A Rare Disease!
Jincy Clement, MD Other Author: Abdulla Damluji MD, MPH, Mike Roberts MD, Matthew Evans MD,
Michael Evans MD, Mike Bayerl MD Departments of Medicine, Anesthesia, Pathology and Division of
Hematology -Oncology.
INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare, aggressive, and potentially lifethreatening
disorder most often affects infants at birth to 18 months of age. We report a case of HLH
secondary to severe Epstein Barr Virus (EBV) in an adult with Common Variable Immunodeficiency
(CVID).
CASE PRESENTATION: A 52 year old man with CVID on weekly Intravenous Immunoglobulin therapy
was admitted for persistent fever up to 104 F for three to four weeks. His examination was significant
for splenomegaly. His lab work showed transaminitis, hyperbilirubinemia, and pancytopenia with
atypical lymphocytes. The peripheral blood smear was notable for marked anisocytosis and moderate
poikilocytosis and dominance of large and medium granular atypical lymphocytes. Cytometry of the
peripheral blood showed predominance of aberrant CD2, CD3, CD5 and CD7 (partial dim) + T-cells,
which was interpreted as reactive or neoplastic in nature.
Bronchoalveolar lavage of pleural fluid from thoracentesis and nasal biopsy were negative for infection
and neoplasm. Infectious work-up was normal. He continued to have persistent neutropenia, anemia,
thrombocytopenia, and recurrent fevers with no identified infectious etiology. A bone marrow biopsy
was performed and revealed findings significant for hemophagocytosis. In the presence of fever,
anemia, thrombocytopenia, splenomegaly, transaminitis; Hemophagocytic Lymphohistiocytosis
diagnosis was made.
Further, our patient met the other diagnostic criteria for HLH including: hypertriglyceridemia (TG: 319
mg/dL) and elevated Ferritin levels (3990 ng/mL ). Given his CVID and large aberrant T cell population,
he was started on immune-suppression with IV solumedrol, Antithymocyte Globulin (ATG) at 40mg/kg
dosed daily for 4 days, and cyclosporine 4mg/kg by mouth twice daily. His EBV titers came
back elevated and his bone marrow stain was highly positive for EBV. Patient had a rough hospital
course with worsening respiratory status. His overall prognosis was very poor and progressed to DIC,
multisystem failure, and subsequently passed away.
DISCUSSION: Hemophagocytic lymphohistiocytosis is a fatal disease with very limited treatment
options. Most of the data on this disease is from children and presentation in adults is very uncommon.
HLH secondary to severe EBV infection with CVID is extremely rare. A diagnosis of hemophagocytic
lymphohistiocytosis should be considered in the setting of chronic pancytopenia and persistent fevers
with no etiology and this case highlights key clinical features associated with HLH to help prevent late
diagnosis.
482

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Julian Manuel Diaz
Fraga, MD
Isolated Ventricular Non-Compaction: An Uncommon Cardiomyopathy.
Julian Manuel Diaz Fraga, MD Elizabeth Dohan, DO Gaurav Gulati, MD Anthony Licata, MD FACC.
INTRODUCTION: Isolated Ventricular Non-Compaction (IVNC) has gained prominence as a rare but
important cause of heart failure. We report a case of this uncommon cardiomyopathy to highlight
diagnosis and management, and review current understanding.
CASE PRESENTATION: A 23 year old female with family history of maternal non-ischemic
cardiomyopathy, presented with insidious onset of lightheadedness and dyspnea on exertion over the
past three months. She denied chest pain, orthopnea, palpitations, edema or syncope. Her vital signs
were normal and negative for orthostatic changes. Physical exam was unremarkable. EKG demonstrated
sinus rhythm with non-specific lateral ST-T wave changes and prominent voltage. A 48 hour Holter
showed no arrhythmias. Echocardiogram revealed diffuse left ventricular hypokinesis (Ejection Fraction:
45%) and significant trabeculation of the left ventricular apex. A stress echocardiogram showed no
evidence of ischemia. A complete blood count, basic metabolic panel, iron panel, ANA, ACE levels,
ionized calcium and ceruloplasmin were all within normal limits. The diagnosis of IVNC was made. She
was started on carvedilol and low dose aspirin. An ACE inhibitor was not added secondary to her wish
for future pregnancy. Retrospectively, on review of her mother’s echocardiogram, findings suggestive of
IVNC were noted. On further probing, she mentioned a similar history in her maternal grandfather who
had a defibrillator placed many years ago.
DISCUSSION: Initially described in 1984, IVNC is a genetic cardiomyopathy with an estimated
prevalence of 0.05% in the general population. It results from a failure of the myocardial compaction
process in the fetus, leading to an altered myocardial structure, seen as prominent left ventricular
trabeculations. It can be either sporadic or familial; therefore, screening of family members is
recommended. Echocardiography is the diagnostic test of choice. Clinical presentation is variable and
includes heart failure, arrhythmias and thromboembolic events. Treatment is directed at arrhythmia and
heart failure management and the prevention of embolic events. ICD implantation is indicated for
secondary prevention but its role in primary prevention is controversial. Long term anticoagulation is
recommended in cases complicated by atrial fibrillation, impaired left ventricular function or
intracardiac thrombi. This case highlights the importance of early diagnosis and familial screening. The
general internist should be familiar with the indications that warrant prophylactic anticoagulation, ICD
implantation and the use of pharmacotherapy to prevent negative remodeling.
483

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Zakiya V Douglas, MD
Isolated cardiac amyloidosis AL type: a rarity and a treatment dilemma
Zakiya V Douglas, MD Second Author: Madhav Gudi, MD Third Author: Kotresha Neelakantappa, MD
Fourth Author: Komal Patel, MD
INTRODUCTION: Primary amyloidosis (AL) is characterized by light chain deposition and is associated
with plasma cell dyscrasia. We present a patient with isolated cardiac amyloidosis of the AL type, which
is rare and whose treatment options are limited and controversial.
CASE PRESENTATION: A 57-year old woman with well-controlled hypertension presented with
gradually worsening anasarca over 8 months and dyspnea on exertion. She had initially noticed
increasing leg edema whose outpatient work-up produced negative results. Physical examination
revealed anasarca, jugular venous distention, decreased breath sounds in the lower lung fields, mild
erythema with weeping of the skin in both legs. She did not have macroglossia or hepatosplenomegaly.
Laboratory values were remarkable for low sodium (132mmol/L) and high thyroid-stimulating hormone
(9.2mU/ml), pro-brain naturetic peptide (7861pg/ml) and troponin T (0.111ng/ml). Serum urea nitrogen,
creatinine, and blood count were unremarkable. Twenty-four-hour total protein excretion was
0.32grams. Serum and urine protein electrophoresis showed no monoclonal band.
Electrocardiogram and echocardiogram revealed left ventricular hypertrophy (LVH), ejection fraction of
55% and increased right ventricular pressures. Computed tomography of the chest, abdomen and pelvis
showed diffuse bowel edema, ascites, pleural effusions, but no masses, adenopathy or organomegaly.
Cardiac magnetic resonance imaging (CRI) revealed mild concentric LVH and delayed hyperenhancement
images consistent with amyloid cardiomyopathy.
Right heart catheterization showed mild-to-moderate pulmonary hypertension at 40mmHg. Endocardial
biopsy was consistent with amyloidosis, lambda light chain type or primary amyloidosis. The patient was
treated with diuretics for heart failure symptoms and is currently undergoing evaluation for heart
transplantation.
DISCUSSION: AL is a systemic disease with multi-organ involvement and high mortality. Only 5% of
patients have isolated cardiac involvement even though the heart is involved in 50% of
patients. Although the diagnosis of amyloidosis can be made on the basis of CRI, tissue diagnosis is
recommended to identify the type of amyloidosis, which guides the treatment and prognosis. Most
patients present with congestive heart failure (CHF) which is resistant to conventional treatment and is a
poor prognostic factor, with a life expectancy of 6 months from the onset of CHF.
Heart transplant followed by high-dose melphalan and autologous stem cell transplantation (HDM-
ASCT) has shown promising results, with 1-3 yr survival in selected patients. A recent study of 350
patients reported short-term to intermediate survival rates of 83%. This was comparable to non-AL
patients with traditional reasons for heart transplant within the same time frame. Our patient satisfies
the exclusion criterion for AL patients by not having clinical evidence of extra-cardiac involvement. Early
recognition and treatment of this rare situation can improve outcomes today.
484

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Donny V Huynh, MD
Flow cytometry in detecting the coexistence of two distinct hematologic malignancies
Donny V Huynh, MD Second Author: Zachariah DeFilipp, MD
INTRODUCTION: Patients with chronic lymphocytic leukemia (CLL) are known to have an increased risk
of developing solid tumors. However, secondary hematologic malignancies are rare. The majority of
reported cases of acute myeloid leukemia (AML) in the presence of CLL are related to previous
chemotherapeutic treatment. Therefore, the simultaneous appearance of these two malignant cell
types in a patient without previous detection is quite exceptional.
CASE PRESENTATION: A 61 year old man with a past medical history of recurrent sinusitis presented
with dyspnea, a productive cough, and a low grade fever which had persisted for one month. He was
transferred to our institution after initial outpatient evaluation revealed pancytopenia and peripheral
blasts. Physical examination revealed scattered rhonchi. Neither lymphadenopathy nor
hepatosplenomegaly were noted. Laboratory studies revealed a hemoglobin 7.4 g/dL, a platelet count
49 x 10 3 /mL, and a white blood cell count 2.9 x 10 9 /L with 52% lymphocytes and 40% blasts. Flow
cytometry identified CD45 dim blasts with an immunophenotype of CD13, CD33, CD34 and HLA-DR. In
addition, a monoclonal B-cell population with an immunophenotype of CD5, CD19, CD20, and CD23 was
unexpectedly detected. Despite of the absolute lymphocyte count of 1.5 x 10 9 /L, a typical CLL
phenotype population was seen. Results of the bone marrow aspirate and biopsy
immunohistochemistry analysis were similar to peripheral blood indicating the simultaneous
appearance of CLL and AML.
DISCUSSION: The concomitant diagnosis of AML and CLL in a patient without previous hematologic
malignancy illustrates a rare phenomenon. However, the exact nature of this patient’s underlying CLL
remains unknown. A diagnosis of CLL requires more than 5000 circulating CLL-phenotype cells per cubic
millimeter, while asymptomatic patients with a lesser number of these cells are diagnosed as CLLphenotype
monoclonal B-cell lymphocytosis (MBL). It is unclear whether the patient had CLL-type MBL
or an underlying low risk CLL now presenting with cytopenias related to acute leukemia. This case
emphasizes the ability of high-sensitivity flow cytometry analysis to detect distinct clonal cell
populations at low levels. Prior to current techniques, this patient would have been informed of a single
acute leukemia. He now faces the uncertainty of a second underlying malignancy. With continued
advances in technology, the simultaneous presence of leukemias and premalignant conditions is an
occurrence we will more frequently encounter in the future.
485

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ruchika Kazi, MD
Weight Gain: A Treatment for Dysautonomia?
Ruchika Kazi, MD Haseeb A Kazi, MD Shamsuddin Shaik, MD Deepakraj Gajanana, MD Bankim Bhatt,
MD
INTRODUCTION:Gastric bypass surgery (GBS) has become common treatment in the management of
morbid obesity. The relationship between hypertension, diabetes and obesity is well-established. In
most cases, the weight loss after GBS has been associated with significant improvement in diabetes and
blood pressure control, but in some cases it can be associated with dysautonomia and prolong disability.
We report a case of severe orthostatic hypotension after rapid weight loss as a result of GBS.
CASE PRESENTATION: A 36-year-old woman with past medical history of morbid obesity (BMI 44.5),
status-post GBS three years ago, was admitted with near syncope and dizziness for 10 months since
surgery. She lost over 175 pounds after her GBS. She noted severe dizziness improved only in the supine
position and worsening of fatigue. On physical examination, she had significant orthostasis without
reflex tachycardia. She also had decreased sensation in the lower extremities with absent patellar
reflexes. The patient had a low am cortisol with an appropriate response to ACTH stimulation. Prolactin
level was elevated (121.2 ng/ml). The rest of the work-up including LH, FSH, estradiol, free T4, TSH, T3,
B12, CBC, CMP, SPEP and UPEP was normal. The Autonomic Nervous System test revealed a decrease in
sympathetic tone causing orthostatic hypotension. Echocardiogram and 24 hour Holter monitoring were
normal. A brain MRI showed an empty sella with compressed pituitary. Multiple tilt table tests and
ambulatory EKG’s were unremarkable. Abdominal wall fat biopsy was negative for amyloid. She was
placed on fludrocortisone, salt tablets, and erythropoietin with slow improvement in the dizziness and
blood pressure. After surgery, the patient also developed hypothyroidism, vitamin D deficiency, and iron
deficiency anemia which responded to treatment initially, but after a few months, with repeated
admissions for refractory syncope, it was thought to be secondary to malabsorption. The patient
ultimately underwent reversal of GBS. To date, the patient is now one year post-reversal and her
orthostatic hypotension has resolved. Her BMI has increased to 23 and iron studies, vitamin D level and
TSH levels are all within normal limits.
DISCUSSION: Orthostasis following rapid weight loss after GBS has been reported. As the number of
these surgeries is increasing, physicians must be aware of possible cardiovascular and neurologic
complications. Treatment frequently includes volume expansion with fludrocortisone and salt tablets
along with erythropoietin. Resistant to conventional therapy and in the case of treatment failure, as in
our patient, one should strongly consider reversal of the GBS.
486

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Haseeb A Kazi, MD
Relentless Diarrhea: Broadening the Differential
Haseeb A Kazi, MD Shamsuddin Shaik, MD
INTRODUCTION:Gastroesophageal reflux disease (GERD) is a common disease often treated with
proton pump inhibitors (PPI). Lymphocytic colitis, a form of microscopic colitis, is a rare entity, which
may be due to certain medications, including proton pump inhibitors or autoimmune disorders.
Symptoms include nausea, abdominal pain, diarrhea, weight loss, and early satiety. We present a case of
lymphocytic colitis from esomeprazole.
CASE PRESENTATION: A 61 year-old female with a history of GERD, hypothyroidism and osteopenia
presented with intermittent nausea, abdominal pain and diarrhea. The diarrhea was bloody and selflimiting,
without any relation to food or sick contacts. There was no history of travel, autoimmune
disease, NSAID use, recent antibiotic use or abnormal collagen metabolism, such as Ehler-Danlos
Syndrome. She had been suffering from these symptoms for approximately one year and had been
treated with multiple courses of metronidazole for nonspecific colitis, with an eight pound weight loss
over that time period. Home medications included esomeprazole, levothyroxine and vitamin D
supplementation. The esomeprazole was prescribed three years prior after being diagnosed with GERD.
Hypothyroidism was long-standing and well controlled. Upon further workup, she underwent an upper
endoscopy and colonoscopy, which showed mild antral gastritis and nonspecific erythema scattered
throughout the colonic mucosa. Biopsy was negative for malignancy, but was consistent with
lymphocytic colitis. Electrolytes, CBC, rheumatologic work-up and thyroid function tests were within
normal limits. Stool studies were negative. The patient continued treatment with esomeprazole and
completed a course of steroids with an improvement in symptoms. Two weeks later, the patient
complained of recurrent diarrhea and nausea. She was made NPO and her diet was slowly advanced as
symptoms resolved. At that time, the esomeprazole was discontinued. It was felt that the lymphocytic
colitis was due to esomeprazole as discontinuation resolved symptoms. To date, there has been no
recurrence of symptoms.
DISCUSSION: Lymphocytic colitis is not often at the top of the differential for diarrhea. Specifically,
proton pump inhibitors as the cause of colitis are uncommon and only a handful of case reports exist
regarding various proton pump inhibitors causing lymphocytic colitis. The exact mechanism and timing
of this side effect is unknown. Esomeprazole is a commonly prescribed medication for GERD. In patients
who present with chronic diarrhea while on this medication, the clinician should consider lymphocytic
colitis in the differential.
487

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ryan Arthur
McConnell, MD
Headache with Hematochezia: A Case of Sumatriptan-Induced Ischemic Colitis
Ryan McConnell, MD Rotonya Carr, MD Allen Hwang, MD Frank Scott, MD Gary Wu, MD
INTRODUCTION: Internists frequently treat migraine headaches, which affect 18% of women and 6% of
men. Sumatriptan (Imitrex), a selective serotonin-1 5-hydroxytryptamine (5-HT1) receptor agonist, is
widely used to abort migraines. The mechanism involves selective intracranial arterial constriction,
though sumatriptan has been implicated in adverse extracranial vascular events. Ischemic colitis results
from hypoperfusion and is the most prevalent form of gastrointestinal (GI) ischemia. It has been
reported with oral contraceptive (OCP) and non-steroidal anti-inflammatory drug (NSAID)
use. Sumatriptan-induced ischemic colitis is rare, reported in only 13 prior cases. Most patients were
young and lacked vascular risk factors typically associated with ischemic colitis, suggesting that ischemic
colitis may be an under-recognized and underreported complication of sumatriptan use.
CASE PRESENTATION: A 37 year-old woman developed acute hematochezia and abdominal pain. She
suffered recent refractory migraine headaches requiring four 50 mg sumatriptan tablets three days prior
to presentation followed by another four tablets plus 440 mg naproxen on the day prior. Within 24
hours of last sumatriptan use, she developed crampy abdominal pain and five episodes of
hematochezia. She denied fever, diarrhea, antibiotic use, and foreign travel. She was a nonsmoker
without vascular disease risk factors, anemia, hypotension, inflammatory bowel disease (IBD), OCP use,
or selective serotonin reuptake inhibitor (SSRI) use. She was afebrile and hemodynamically stable. She
exhibited left lower quadrant tenderness. Bowel sounds were normal. Anoscopy revealed blood
proximal to the pectinate line. Hemoglobin, WBC count, erythrocyte sedimentation rate, and C-reactive
protein were normal. Stool was negative for bacterial pathogens and C. difficile toxin. CT scan revealed
“moderate mural thickening with mild surrounding inflammatory changes involving the distal transverse
and proximal descending colon.” Colonoscopy showed a 20-centimeter splenic flexural region of
erythematous mucosa with punctate submucosal hemorrhage. Biopsy was negative for pathologic
change. The abnormalities had resolved upon repeat colonoscopy 6 weeks later. The patient began
propranolol for migraine prophylaxis and reports no further GI symptoms for 10 months off
sumatriptan.
DISCUSSION: This is the second-youngest victim and 14 th reported case of sumatriptan-induced
ischemic colitis. The association is strengthened by the temporal relationship, large dose, absence of
IBD and infection, and lack of vascular risk factors. Although this patient took large doses, only five of 14
reported cases (36%) occurred with sumatriptan dose escalations. A prior case lacked hematochezia
entirely, raising the possibility that numerous cases go undiagnosed in younger, otherwise healthy
patients. The patient’s naproxen use suggests possible synergistic medication effect. Four of 14
patients (29%) took SSRIs and another 29% took NSAIDs. A combination sumatriptan/naproxen therapy
(Treximet) is approved for migraines, which may be a safety concern. This case highlights the
importance of adverse reaction reporting and may have implications for limiting sumatriptan doses for
migraines.
488

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Bonita A Mohamed,
MD
SMEAR UNFOLDS THE MYSTERY
Bonita A Mohamed, MD Contributing Authors: Harish Raj Seetha Rammohan MD and Ingrid Kohut DO
INTRODUCTION:Gemcitabine-associated thrombotic thrombocytopenic purpura (TTP) is a rare
complication of gemcitabine treatment with an incidence ranging from 0.015% to 1.4%. We describe a
case of thrombocytopenia refractory to platelet transfusions in the setting of recent therapy with
gemcitabine.
CASE PRESENTATION: A 72-year-old Hispanic female with a past medical history of metastatic breast
cancer, right pleurodesis, hypertension, and Type II diabetes mellitus presented with dyspnea on
exertion for three days. On admission, patient had CT Thorax with contrast which confirmed bilateral
pulmonary embolism. Patient received chemotherapy with gemcitabine four days prior to admission.
Initial assessment revealed stable hemodynamic parameters, bilateral lower extremity edema with
tenderness and palpable purpura, and decreased breath sounds on right hemithorax.
CBC showed a leukocyte count of 1,300 mm 3 , hemoglobin of 7.3 g/dL, hematocrit of 21.4%, and a
platelet count of 16,000 mm 3 . Electrolyte panel was notable for a BUN 28 mg/dL, creatinine 1.24 mg/dL
and CO2 35 mmol/L. Ultrasonography confirmed an occlusive left popliteal and peroneal deep-vein
thrombosis. A 2D echo revealed normal left ventricular ejection fraction and no right ventricular heart
strain. Chest X-ray was equivocal. Clinical impressions at the time were dyspnea secondary to
pulmonary embolism and pancytopenia secondary to chemotherapy.
Patient was placed on a heparin infusion for pulmonary embolism (PE), packed red blood cell and
platelet transfusions were initiated for anemia and thrombocytopenia, respectively. Patient had
continued thrombocytopenia, refractory to multiple platelet transfusions. Heparin-induced
thrombocytopenia panel was negative and coagulation profile within normal range. Additional labs
included LDH 238 IU/L, haptoglobin 64 mg/dL, and reticulocyte count 3.2%. Peripheral blood smear
revealed schistocytosis and the working diagnosis was changed to gemcitabine-associated TTP. Heparin
was discontinued and an IVC filter was placed. Plasmapheresis was initiated concurrently with steroid
therapy and the platelet count recovered to greater than 100,000 mm 3 after 11 cycles. At discharge
patient maintained her platelet count and no longer required plasmapheresis.
DISCUSSION: It is important for clinicians to have delicate suspicion of TTP in patients with anemia and
thrombocytopenia in the setting of gemcitabine use. This case presents a diagnostic challenge as
anemia and thrombocytopenia are common adverse effects of gemcitabine. Diagnosis and
management in this case was further complicated by subsequent PE therapy. Refractory
thrombocytopenia and peripheral smear were integral in raising suspicion for TTP, as not all the
common features were exhibited in our patient. Plasmapheresis with steroid therapy proved
fundamental to recovery of platelet count. This case sheds light on the role of gemcitabine in
microangiopathic processes and the need for further investigations of the pathophysiology. Early
diagnosis and initiation of therapy proved vital in this case.
489

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Juhi Moon, MD
Toes to the lungs: Disseminated Osteomyelitis and Pulmonary Mucormycosis in a M5, Acute Myeloid
Leukemic.
Juhi Moon, MD Entezam A. Sahovic, MD
INTRODUCTION: Mucormycosis is an uncommon filamentous fungi known to cause invasive rhinocerebral
disease. Our patient is unique in that he developed breakthrough mucor infection of the bone
and lung while on voriconazole, an occurrence rate of only 0.5%. Furthermore, without having risk
factors for a point of entry such as trauma or burns, our patient developed osteomyelitis and
necrosis. Recent studies revealed deep and extensive muscle or bone disease to occur in only 4.6% of
the infected.
CASE PRESENTATION: Our patient is a 47-year-old Caucasian male with a history of AML, M5 type who
was admitted because of an incidental finding of leukopenia by his family doctor. Bone marrow biopsy
revealed acute leukemia and he underwent induction chemotherapy withDAE. Fourteen days later,
biopsy revealed no residual leukemia. However, due to persistent neutropenia he completed the
modified Capizzi regimen. Two weeks later, he developed neutropenic fever and empiric cefepime and
daptomycin were started. Despite therapy, fevers continued and voriconazole was added
empirically. The patient then complained of left foot pain. His vital signs were 38.4 C, 73 bpm, 18
breath/min, and blood pressure 122/80. Physical exam found the left hallux warm, edematous, dry, and
tender to palpation. Doralis pedis pulse was absent on the left foot, but there was no cyanosis or
ulcerations. Pertinent labwork included hemoglobin 7.9, white blood cell 0.016, platelets 15, creatinine
kinase 20, and uric acid 1.1. In the following days, erythema and edema encompassed the entire left
foot and left leg. Due to the pain, extent, and rapidity of disease the patient underwent a left hallux
amputation. Pathological examination of the hallux bone revealed extravascular, branching fungal
hyphae, morphologically consistent with mucormycosis. Antifungal therapy was then changed to
amphotericin B and posiconazole. Four days later the patient started to complain of acute onset rightsided
chest pain. Lung exam revealed diminished breath sounds. CT chest showed right upper lobe
pneumonia and BAL was negative. Due to the recent discovery of mucormycosis in the toe,
cardiothoracic surgery performed a right upper lobe lobectomy. Pathology report revealed many large
blood vessels filled and occluded by fungal hyphae, consistent with mucormycosis. This was
accompanied by a pulmonary infarct and adjacent suppurative inflammation and extensive organizing
pneumonia. Post-operatively the patient was on long-term antifungal treatment and even achieved
complete remission from his leukemia and is now disease free for the past 4 years.
DISCUSSION: As evidenced by pathology reports our patient experience local infiltration and vascular
invasion causing toe necrosis and acute fungal osteomyelitis, which precluded good antifungal
penetration. Furthermore, pulmonary angioinvasion, thrombosis-causing pulmonary infarction, and
abscess formation also compromised antifungal efficacy. A recent study showed decreased mortality for
pulmonary mucor from 55% to 27% with surgical intervention. In addition delayed initiation of an
amphotericin-B based regimen has been reported to be associated with doubled mortality at 12
weeks. Consequently, adequate surgical intervention is required for successful treatment of
mucormycosis in addition to early and prolonged antifungal therapy.
490

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ji Hyun Rhee, MD
Cocaine Washout Syndrome : A Rare Case Presentation With Refractory Shock
Ji Hyun Rhee, MD V. Sandeep Yadavalli MD, Parit Mekaroonkamol MD, Rene Franco Elizondo MD, K.
Randall Young MD, Adam K. Rowden DO Albert Einstein Medical Center
INTRODUCTION: Cocaine washout syndrome is a rare complication of prolonged cocaine use
manifested by brief coma that resolves spontaneously. There are no data on the incidence or exact
pathophysiology of this syndrome; only 3 cases have been reported in the literature since the 1990s.
The proposed mechanism is depletion of adrenergic neurotransmitters due to prolonged and persistent
stimulation. Here we report an unusually extreme presentation with coma and refractory shock.
CASE PRESENTATION: A 33-year-old African-American woman with history of chronic cocaine abuse
was brought to the emergency department (ED) unresponsive. The patient was last seen sic “stoned” by
her mother 6 hours prior to arrival. She was given naloxone in the field with no improvement in mental
status. In the ED, vital signs showed hypotension (61/24mmHg), tachycardia (132bpm), hypoxia (90% on
ambient air) and hypothermia (33.9°C) without cold exposure. Physical examination revealed a
comatose patient with Glasgow Coma Scale of 3, covered in vomit, with no gag, cough, corneal reflex, no
nystagmus and sluggishly reactive non-dilated pupils. Remaining physical exam findings were
unremarkable. The patient was intubated for airway protection. Chest radiograph and head CT did not
reveal any acute pathologic process while lab results showed acute kidney injury, increased liver
enzymes up to 1000s, leukocytosis, respiratory and anion gap metabolic acidosis with pH 7.08, pCO2
48mmHg, HCO3 12mmol/L and lactate of 64mg/dL. Urine toxicological screening was positive for
cocaine, benzodiazepines, opioids and phencyclidine (PCP), while blood analyses were negative for
alcohol, acetaminophen, salicylates and serum osmolar gap. Despite aggressive fluid resuscitation and 4
vasopressor agents at maximal infusion rates, she remained hypotensive and anuric. Stress dose steroids
and antibiotics were empirically started. However, only 8 hours after admission, her gag, cough and
corneal reflexes were back. Her hemodynamic status also dramatically improved and vasopressors were
being successfully weaned. The following day, she was off vasopressors, her mental status returned to
baseline and was ready to resume spontaneous ventilation. As blood cultures and cosyntropin test were
negative, antibiotics and steroids were discontinued. After being extubated on day 2, she admitted to
daily cocaine use for several months, with a binge episode laced with other drugs on the day of
admission. After psychiatry was consulted and ancillary support was set up, the patient was discharged
home in a stable condition.
DISCUSSION: This case outlines a rare but potentially fatal complication of acute cocaine intoxication.
Hypotension and lack of nystagmus eliminated PCP intoxication as a cause while tachycardia did not
favor benzodiazepines or other sedative-hypnotics. Cocaine washout syndrome remains a diagnosis of
exclusion in patients with corroborative history and high clinical suspicion. Patients should be admitted
to the appropriate level of monitoring; i.e. intensive care unit. Aggressive fluid resuscitation with
meticulous hemodynamic and ventilatory support is the cornerstone of management in cocaine
washout syndrome.
491

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ji Hyun Rhee, MD
Tamoxifen associated Budd-Chiari syndrome complicated by heparin-induced thrombocytopenia and
thrombosis
Ji Hyun Rhee, MD Maneerat Chayanupatkul MD, Anand Raman Kumar MD, Manjula Balasubramanian
MD, Gabor Varadi MD Albert Einstein Medical Center
INTRODUCTION: Budd-Chiari syndrome (BCS) is a pathophysiologic process that is characterized by
hepatic venous outflow obstruction at any level from hepatic venule to right atrium, regardless of the
cause of obstruction. Frequently, patients have one or more underlying thrombophilic conditions that
predispose to BCS. Here we report a rare case of BCS associated with Tamoxifen use which was later
complicated by heparin-induced thrombocytopenia and venous thrombosis.
CASE PRESENTATION: A 44-year-old female with a past medical history of atypical ductal hyperplasia
and lobular carcinoma in situ, who had been on tamoxifen for chemoprevention for 2 years, presented
with diffuse abdominal pain and increased abdominal girth for 1 month. She was an ex-smoker and had
a significant family history of ovarian and breast cancer. Review of systems and other social and past
medical history were unremarkable. Physical examination revealed abdominal distention with positive
fluid wave, hepatosplenomegaly and pedal edema. The patient had no other stigmata or history of
chronic liver disease. Laboratory studies apart from mildly increased alkaline phosphatase and low
albumin were normal including blood count. Viral and autoimmune markers were negative. Imaging
studies including hepatic ultrasound with dopplers and a computed tomography (CT) of the abdomen
with contrast followed by a liver biopsy showed findings diagnostic of BCS. Work-up for hypercoagulable
states revealed an unclassified occult myeloproliferative disorder with a positive JAK-2 V617 mutation in
peripheral blood and bone marrow. Erythropoietin level was normal. Tamoxifen was discontinued and
the patient was treated with intravenous heparin and transjugular intrahepatic portosystemic shunt
(TIPS) for decompression. Subsequently, the patient developed heparin induced thrombocytopenia and
thrombosis (HITT) and TIPS occlusion. This complication led to rescue therapy which entailed TIPS
revision and change in anticoagulant therapy to argatroban. The platelet count increased to normal in 4
days. Follow-up hepatic ultrasound with dopplers showed patent TIPS and the patient was successfully
bridged to Coumadin.
DISCUSSION: This case emphasizes a rare but catastrophic complication of BCS with Tamoxifen. To the
best of our knowledge, this is the first report of Tamoxifen associated hepatic venous thrombosis.
Underlying myeloproliferative condition like JAK-2 mutation is highly prevalent in BCS and needs to be
tested in all patients with BCS. Finally, since patients with BCS are more prone to develop HITT,
anticoagulation and blood count need to be carefully monitored and the possibility of HITT emergence
should always be kept in mind.
492

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Shamsuddin Shaik,
MBBS
A New Twist on a Known Side-Effect of Piperacillin-tazobactam
Shamsuddin Shaik, MD Haseeb A Kazi, MD Peter T Ender, MD
INTRODUCTION:Piperacillin/tazobactam is a commonly prescribed antibiotic and is generally
considered safe with minimal side effects. Thrombocytopenia is a known side effect, with a reported
onset of 11-21 days. We report a case of immediate thrombocytopenia after one dose of
piperacillin/tazobactam.
CASE PRESENTATION: A 47 year-old Hispanic female with a history chronic lung disease and HIV on
stable antiretroviral therapy for >1 year with a CD4 >200 for last 6 months was admitted with one week
of fever, chills and productive cough. She had multiple admissions for resistant pseudomonal and
pneumococcal pneumonia in the recent past, including ventilatory dependent respiratory failure. During
this admission, she was started on ceftriaxone and azithromycin for community acquired pneumonia.
Her CBC on the day of admission showed a hemoglobin of 11.2 g/dl, WBC 17.76 thousand/uL, and
platelets 198 thousand/uL. On day two, piperacillin/tazobactam was started at 4.5 g IV q6h to cover for
Pseudomonas aeruginosa. After one dose of piperacillin/tazobactam, platelets on the following day
were 7.0 thousand/uL. Her repeat platelet count five hours later was 4.0 thousand/uL.
Piperacillin/tazobactam was discontinued and was replaced with aztreonam. There was no heparin
exposure and there was no evidence of hemolysis or DIC. She had petechiae noted on her arm, but no
other signs of overt bleeding. After 6 units of platelets were transfused, the count improved to 33
thousand/uL on the same day. Her platelet count five days after discontinuation of
piperacillin/tazobactam was 133 thousand/uL without any intervention. Another hospitalization
occurred five months later with symptoms of fever and worsening cough. Initial platelet count was 157
thousand/uL. After a single dose of piperacillin/tazobactam, platelets the next day were 40 thousand/uL.
Due to the previous history of suspected thrombocytopenia from piperacillin/tazobactam, the antibiotic
was switched to meropenem 1g IV q8h. Her platelets slowly improved and by the sixth day were 183
thousand/uL. Given that the platelets dropped precipitously with rechallenge and recovered both times
without any change in the treatment of HIV or treatment of HIV associated ITP, it was felt that the
thrombocytopenia was due to piperacillin/tazobactam.
DISCUSSION: Thrombocytopenia is a serious, but uncommon adverse effect of piperacillin/tazobactam
and should be kept in mind while treating patients. The previously reported cases of thrombocytopenia
have been gradual in onset, all occurring at >10 days. This case is unique in the rapid onset of
thrombocytopenia, and the cause was confirmed with rechallenge and recovery of the platelets
occurred with discontinuation of only the piperacillin/tazobactam. We hypothesize that a unique
mechanism of action may cause a more rapid onset of thrombocytopenia with piperacillin/tazobactam.
493

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Shailendra Singh, MD
Obstructive Jaundice, A rare complication of laparoscopic right hemicolectomy treated
endoscopically.
Shailendra Singh, MD, Shyam Thakkar, MD
INTRODUCTION:Benign bile duct strictures postoperatively are major iatrogenic catastrophe and
usually are complications of surgery for gallbladder stones, both open surgery and laparoscopic surgery.
Laparoscopic colectomies are routinely performed for large and endoscopically unresectable polyps.
However, development of biliary stricture after laparoscopic right hemicolectomy is an extremely rare
condition and has not been reported in literature.
CASE PRESENTATION: A 64 year old white female was referred to our institution for further evaluation
and treatment of biliary complications after laparoscopic hemicolectomy. One week post laparoscopic
surgery she developed sudden onset jaundice with dark urine, nausea and increasing epigastric and right
upper quadrant abdominal pain. Physical examination revealed jaundice; mild tenderness in the right
upper abdominal quadrant but no palpable mass or ascitis and the surgical scar was healed
appropriately. Initial laboratory reports revealed an total bilirubin 10.8 mg/dl, direct bilirubin 6 mg/dl,
alkaline phosphatase 306 U/L, alanine aminotransferase 307 U/L and aspartate aminotransferase 181
U/L. Imaging studies revealed biliary dilation of both extra and intra hepatic ducts with no evidence of
bile duct stones. The ERCP showed an abrupt, complete obstruction of the CBD at the level of the
surgical clips and multiple surgical clips across the CBD. The stricture improved significantly after serial
incremental biliary dilatations with successive placement of increasing number of endoprostheses side
by side at repeat ERCP sessions.
DISCUSSION: Bile duct injury and stricture formation is not a known complication of right
hemicolectomy but bile duct injury following laparoscopic right hemicolectomy is a possibility given the
anatomical proximity of the right colon and hepatobiliary structures. We believe that bile duct injury in
this patient was most likely a result of misplacement of surgical clips across the CBD. Early diagnosis of
these biliary strictures is imperative to prevent irreversible fibrosis and life-threatening complications,
such as ascending cholangitis, liver abscess, and secondary biliary cirrhosis. Post operative bile duct
injuries have been traditionally treated by surgical repair, usually a biliodigestive anastomosis mostly a
proximal hepatico-jejunostomy with Roux-en-Y jejunal loop, but today endoscopic treatment is
preferred. The excellent result obtained in our patient suggest that if the occluding surgical clip or the
biliary stricture secondary to surgical clip is susceptible to dilation and stent insertion, endoscopic
dilation and stent insertion should be adopted as a less invasive, first line approach to this problem as it
can avoid a complicated and morbid surgical bypass.
494

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Daniel John Spinuzzi,
MD MBA
Pheochromocytoma Presenting As Cardiogenic Shock: An Atypical Case.
Daniel John Spinuzzi M.D./M.B.A., William Rust M.D.
INTRODUCTION: Pheochromocytoma is a rare neuroendocrine tumor derived from enterochromaffin
cells and is found in less than 0.3% of hypertensive individuals. 0.01% present with shock. Symptoms
typically include a triad of headache, palpitations and diaphoresis. Less common manifestations include
acute myocardial infarction, arrhythmias, dilated cardiomyopathy, and in extreme cases, acute heart
failure. We describe a patient presenting with cardiogenic shock and respiratory failure initially
diagnosed with viral myocarditis and subsequently found to have a pheochromocytoma.
CASE PRESENTATION: A 51 year old white female with a past medical history of hypertension
presented to the emergency department complaining of chest pain, shortness of breath and several
episodes of emesis over the preceding 2 days. Vital signs include a blood pressure of 60/30 mm Hg,
heart rate of 130 beats per minute and respiratory rate of 34 /min. Physical exam revealed bilateral
crackles and cool extremities. Sinus tachycardia with diffuse ST segment and T wave changes were seen
on the initial electrocardiogram. She has a leukocyte count of 19.7 k/ml, BUN of 27 mg/dL, creatinine of
2.5 mg/dL, and elevated cardiac enzymes. An arterial blood gas revealed a pH of 6.99 and HCO3 of 6.6.
Chest X-Ray revealed bilateral pulmonary edema. She was emergently intubated, and started on
dopamine and dobutamine. An emergent cardiac catheterization revealed normal coronary arteries and
severe left ventricular dysfunction with an ejection of 10%. An intra-aortic balloon pump was placed for
hemodynamic support and the patient was evaluated for possible left ventricular assist device.
In the CCU, systolic blood pressure ranged from 90-220 mm Hg and HR ranged from 120-280 bpm. She
had urine metanephrine of 3195, total metanephrine 4838 and normetanephrine of 1643. Antihypertensive
medical therapy included phentolamine, phenoxybenzamine and labetolol. Computed
Tomography revealed a left adrenal mass highly suspicious for pheochromocytoma. Pathology from an
abdominal tumor resection confirmed the diagnosis. The hospital course was complicated by acute renal
failure and respiratory failure. She gradually improved post-operatively and a repeat echocardiogram
revealed an EF of 65%. She was discharged to home without anti-hypertensive therapy.
DISCUSSION: This case illustrates a near fatal presentation of Pheochromocytoma. Sudden release of
catecholamines may precipitate hemodynamic compromise and multi-system organ failure. Cardiac
manifestations may include arrhythmias, angina, myocardial infarction, and acute heart failure.
Catecholamine induced focal myocardial necrosis with inflammatory infiltration can cause pulmonary
edema and LV dysfunction as seen in this patient and appears to be reversible with both medical
management and subsequent removal of the tumor.
Although rare, pheochromocytoma should be considered in patients that present with cardiogenic shock
of unknown etiology. This case illustrates the significant morbidity and mortality associated with
pheochromocytoma and the importance of recognizing its various clinical manifestations.
495

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Daniel John Spinuzzi,
MD MBA
A Case of Capnocytophagus and the Future of Identifying Infectious Disease Pathogens
Daniel John Spinuzzi, MD MBA. William Rust M.D.
INTRODUCTION:
Capnocytophagus is a gram-negative bacillus that is part of the normal canine flora. The bacterium can
cause devastating DIC, especially in asplenics. The organism requires an oxygen-rich environment and is
difficult to isolate in culture. This vignette describes an asplenic patient presenting with overwhelming
sepsis due to Capnocytophagus. The bacterium was unable to be isolated in culture at our facility and
was only identified with Ibis T5000 technology.
CASE PRESENTATION:
A 67-year-old man presented with altered mental status and acute respiratory failure. He is asplenic
secondary to a prior gunshot wound. The patient’s wife reported acute onset of “confusion” on the
evening prior, along with several episodes of vomiting, a temperature of 104 degrees Fahrenheit and a
non-productive cough. The patient was febrile at 105.2 and had a white blood count of 16.6. He was
pan-cultured and started on vancomycin, ceftriaxone, acyclovir, as well as steroids for presumed
meningitis. A lumbar puncture was unable to be performed because of a TENS unit. The patient was
intubated and had cold extremities with multiple petechiae. The tip of his nose was also involved and
cultures were redrawn. When checking a blood culture the lab noted “rod-shaped bacteria intra/extracellularly.”
On hospital day one, the wife asked if a “dog bite” could be responsible, as the family dog
“nipped” at the patient’s nose and caused a minor break in the skin on the day prior to evaluation. The
differential now included Capnocytophaga Canimorsus. The patient’s DIC persisted and his
extremity/nose necrosis continued to worsen. His somnolence continued despite sedation
discontinuation. The family requested withdrawal. Multiple cultures from our facility were negative, as
well as samples sent to outside facilities. The initial blood culture was later reported as likely
Capnocytophagus species. Post-mortem, six of the blood samples were analyzed using state-of-the-art
Ibis T5000, which is a universal biosensor that allows one to identify a broad range of pathogens without
requiring an anticipated organism. All six of our patient’s samples were positive with Capnocytophaga
Canimorsus.
DISCUSSION: This vignette highlights the importance of identifying Capnocytophagus as a potential
source of sepsis in those at risk. Due to fastidious growth requirements Capnocytophagus is difficult to
culture. This case introduces Ibis T5000 technology as a potential game-changer in the world of
infectious disease and patient care. The system incorporates mass spectrometry and PCR technology to
identify a broad range of pathogens such as bacteria, fungi, viruses, and protozoa including their
resistance factors, in less than eight hours. The technology allowed us to identify an organism that we
were unable to grow in culture.
496

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Matthew J
Stanishewski, DO
White Matter Abnormalities In A Patient With Legionerres’ Disease
Matthew J Stanishewski, DO, Associate, Department of Medicine, Lankenau Hospital, Wynnewood
Pennsylvania
INTRODUCTION:The neurological manifestations seen in patients diagnosed with Legionerres’ disease
have been well documented. Forty to fifty percent of cases will develop neurological signs and
symptoms. However, radiological abnormalities accounting for these manifestations are exceedingly
rare.
CASE PRESENTATION: A 45 year old African American female with no significant past medical history
presented after developing dry cough and fever with sudden onset of ataxia and profound
dysarthria. Her chest x-ray showed a right lower lobe infiltrate with lab studies showing mild elevation
in her liver enzymes. In addition, a non-contrast computed tomography scan of the brain showed subtle
peripheral subcortical white matter hypodensities without evidence of acute disease. A brain magnetic
imaging study revealed numerous centrifugally placed, nonspecific foci of white matter signal
abnormality on T2-weighted and FLAIR sequences. Initially, she was treated empirically with
intravenous levofloxacin and metronidazole. Within 24 hours, the patient’s ataxia had significantly
improved, however, she continued to experience considerable dysarthria. A urinary legionella antigen
was found to be positive the following day. Anti-nuclear antibodies, anti-neutrophil cytoplasmic
antibodies and anticardiolipin antibodies were negative. An echocardiogram revealed normal left
ventricular function without evidence of thrombi. Her antibiotic therapy was tailored to levofloxacin
alone and within 48 hours of treatment, her dysarthria had significantly improved. By 72 hours, her
symptoms had completely resolved. She was subsequently discharged on a full 21 day course of oral
levofloxacin, without recurrence of her neurological sequelae.
DISCUSSION: Previous case reports have demonstrated various brain imaging abnormalities associated
with Legionella infection. Cases of reversible brain lesions have been reported. The mechanism of
neurological dysfunction in patients with Legionella pneumophila is currently unknown. One hypothesis
proposes an endotoxin-mediated effect on central nervous system tissue. The lesions seen in our
patient may represent cytotoxic edema in the setting of this proposed phenomenon. Due to the
increasing availability of sensitive imaging methods, the finding of brain lesions in patients with
Legionerres’ disease may be more common than previously acknowledged.
497

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Rashmi V Thatte,
MBBS
SEVERE VITAMIN B12 DEFICIENCY MIMICKING THROMBOTIC THROMBOCYTOPENIC PURPURA
Rashmi V Thatte MD
INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is a diagnosis made by clinical and
biochemical features constituting the classic “pentad”: thrombocytopenia, microangiopathic hemolytic
anemia (MAHA), fever, acute renal failure and neurological symptoms. Reversible causes like Vitamin
B12 deficiency can also present similarly and should be ruled out in all patients with suspected TTP.
CASE PRESENTATION: 83 year old African American male presented to the ER with complaints of
recent onset of severe weakness, loss of appetite and syncope. The review of systems was otherwise
negative and the physical examination only revealed pallor. Past medical history was positive for reflux
disease and colon cancer status post resection over 15 years ago. In the ED, laboratory results showed
pancytopenia (white blood cell count of 3600/µL, hemoglobin of 5.5 g/dl with MCV of 93.8 fL and
platelet count of 54,000/ µL), elevated creatinine of 2.3 mg/dl and indirect hyperbilirubinemia (indirect
bilirubin = 2.3 mg/dl). Due to a very high clinical suspicion of TTP, a stat hematology consult was placed
and the peripheral smear was reviewed immediately .The smear showed rare, isolated schistocytes and
hence, plasmapharesis was held based on absence of evidence of active intravascular hemolysis.
Subsequent tests confirmed hemolysis with lactate dehydrogenase (LDH) elevation to 1765 units/L and
haptoglobin level < 10 mg/dl but suggested a bone marrow pathology as reticulocyte count was
inappropriately normal (1.8%) for the severity of anemia. Direct and indirect Coomb’s tests were
negative. The platelets continued to drop with a nadir of 17,000 / µL. Prior to subjecting the patient to
an invasive bone marrow biopsy, vitamin B12 and folate levels were ordered. Folate level was normal (
12.8 ng/ml ) but a vitamin B12 level of 42 pg/ml suggested severe deficiency , confirmed by a very high
methylmalonic acid level ( 4000 nanomoles/ liter) and a high homocysteine level ( 20 micromoles/liter).
Intrinsic factor antibodies were negative ruling out pernicious anemia. The patient was given
intramuscular injections of 1000 micrograms of vitamin B12 daily for one week with a marked response
of the platelet count and reticulocyte count along with a gradual downward trend of LDH.
DISCUSSION: Vitamin B12 deficiency causes pancytopenia by direct bone marrow suppression. It is also
thought to cause intramedullary hemolysis due to increase red blood cell membrane rigidity. Lysis of
immature nucleated red cells in the bone marrow can lead to an elevated LDH level, a microangiopathic
smear, and a low haptoglobin level. Simple tests like peripheral smear, vitamin B12 level and
methylmalonic acid level can be extremely useful in ruling out a deficiency state which can clinically
present like TTP.
498

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jayaram R
Thimmapuram, MBBS
Pneumopericardium, Pneumomediastinum, Pneumoperitoneum, Pneumoretroperitoneum and
Subcutaneous Emphysema Post Colonoscopy.
Hao Nguyen, MD Second Author: Jayaram Thimmapuram, MD Third Author: Vipul Bhatia, MD
INTRODUCTION: Colonoscopy is a widely performed procedure. Bowel perforation is a rare
complication reported in about 0.4-1.9% of cases. It is the most serious and awful adverse event which
can lead to a death. Supradiaphragmatic complications of colonoscopy have been rarely reported. We
report a rare case of pneumopericardium, pneumomediastinum, pneumoretroperitoneum,
pneumoperitoneum and subcutaneous emphysema after a colonoscopic procedure without evidence of
perforation.
CASE PRESENTATION: A 76-year-old caucasian female with history of uncontrolled hypertension and
hypothyroidism underwent an elective screening colonoscopy. Her medications included
hydrochlorothiazide, omeprazole, multivitamins and fexofenadine. Colonoscopy revealed four small
polyps which were removed successfully without any major bleeding observed. However, about thirty
minutes following the colonoscopy, patient had an acute onset of severe retrosternal chest pain, sharp
and pressure like in nature, rated to be 10/10 that started from the anterior retrosternal and radiating
to her back. The chest pain was constant but improved slightly with intravenous pain medication.
However, the episodes of pain came back again. The pain worsened with deep inspiration. During the
event, her blood pressure was found to be 197/92 with heart rate of 110. Her saturation however,
maintained 95% at 2 Litter of Oxygen through nasal canula. An urgent CAT scan of the chest, abdomen
and pelvis was done which showed pneumomediastinum and pneumopericardium with air dissecting
into the neck and the retroperitoneum and into the abdominal wall muscles on the right. Urgent
exploratory laporoscopy was done which did not show any evidence of perforation. Patient clinically
improved after the procedure and hemodynamically stable with routine medical care. Intravenous
levofloxacin and metrodinazole were started empirically. She responded well with conservative
management without a laparotomy. She tolerated slowly advanced diets. Patient was discharged after 4
days with oral metrodinazole for 3 more days and set outpatient follow up with gastroenterologist and
surgeon.
DISCUSSION: Colonic perforation can lead to extra intestinal collection of air. However,
supradiaphragmatic complications including pneumomediastinum and pneumopericardium have been
only rarely reported. In our patient, there was no evidence of perforation seen on exploratory
laparoscopy. Different mechanisms have been proposed whereby extra-luminal air may reach the
different body compartments. Forcible herniation of the colonic mucosa has been suggested, such that
the mucosa becomes permeable to air without an actual perforation developing. Air may pass along the
mesentery to the retroperitoneum and then to the mediastinum along the fascial planes.
Pneumomediastinum can lead to a pneumothorax or pneumopericardium when the mediastinal parietal
pleura or the pericardium ruptures. In summary, we describe an interesting case of extraluminal and
supradiaphragmatic collection of air post colonoscopy without evidence of perforation.
499

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Aubre A Weber, DO
Treating Steroid-refractory Dermatomyositis Associated with Severe Dysphagia with Intravenous
Immune Globulin
Aubre A Weber, DO, Associate, Shakaib S. Qureshi, MD, Section Chief - Department of Rheumatology,
Christiana Care Health System, Newark, DE.
INTRODUCTION: Dysphagia associated with dermatomyositis is often treated with corticosteroids and
later with immunosuppressive maintenance therapies. Intravenous immune globulin (IVIG) is
not currently used as first line treatment for complications arising from dermatomyositis. However, new
literature has suggested that in complement-damaged tissue as seen in this inflammatory myopathy,
IVIG appears to modulate and minimize complement attack.
CASE PRESENTATION: A 63 yr old Hispanic female presented with a diffuse macular rash and upper
extremity weakness. On exam, she was noted to have diffuse anasarca, an erythematous, macular rash
over her eyes, neck, shoulders, gottron’s papules on bilateral PIP and MCP joints and symmetric
proximal weakness noted in her upper extremities. Muscle biopsy showed an inflammatory myopathy
with serology demonstrating elevated sedimentation rate, creatinine kinase (CK), aldolase, liver function
tests, as well as a positive ribonucleoprotein (RNP) antibogy IgG and anti-Ro IgG antibodies. She was
diagnosed with dermatomyositis during this visit and discharged with a steroid taper and follow up with
rheumatology. Unfortunately, she returned to the emergency department one week later with
dysphagia. Speech therapy witnessed large silent aspiration events on exam and the patient had a
feeding tube placed shortly thereafter. Again, the patient was placed on steroids with little effect. No
improvement was observed in the patient’s dysphagia and in fact, her liver function, muscle enzymes
and overall condition continued to worsen. Decision was made to treat with IVIG administration,
400mg/kg/day for 5 days, which she tolerated well. Her laboratory data progressively improved and
approximately 9-10 days after IVIG infusion, swallow evaluation showed patient to be protecting her
airway when given thickened liquids. Her diet was advanced and steroid taper was started. Treatment
with azathioprine was considered but her TMPT status was tested and she was determined to be
deficient. A small portion of the population is TPMT-deficient. Low TMPT levels can lead to thiopurine
drugs, such as azathioprine, being inefficiently metabolized. This can lead to severe and possibly fatal
toxicity as the unmetabolized drug accrues in the bone marrow. The risk of methotrexate therapy was
also high due to resolving transaminitis so the patient was eventually discharged with continued steroid
taper and IVIG follow-up infusions monthly for 3-6 months.
DISCUSSION: Although effectiveness has been shown in some small studies using IVIG in
dermatomyositis-related complications such as dysphagia, the mechanism of its action is still not
completely clear. This case highlights the need for further research in regards to treating steroidrefractory
dermatomyositis associated with severe complications with IVIG. In addition, IVIG as a single
maintenance therapy in patients with a documented inability to receive maintenance therapies such as
methotrexate and/or azithioprine has yet to be clearly shown as a reliable treatment
modality. Dysphagia associated with dermatomyositis leads to an elevated mortality rate, and a proven
as well as consistent acute and maintenance therapy in this potentially life-threatening condition is
necessary.
500

PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Zhineng Jayson Yang,
MD
Jejunal Diverticulitis: A Rare Cause Of Abdominal Pain
Yang ZJ, Ripepi BM, Fritz JM, Rahman A, Nusrat S
INTRODUCTION: The prevalence of jejunal diverticula is estimated to be 1.1-2.3%. Complications of
jejunal diverticular disease (JDD) include diverticulitis, hemorrhage, bowel obstruction, perforation and
blind loop syndrome. JDD can present as acute abdomen or chronically with non-specific symptoms such
as nausea, emesis or recurrent central/upper abdominal pain that may mimic gastritis, peptic disease or
irritable bowel syndrome. As a rare entity, the diagnosis of JDD is often not deliberated and is frequently
made incidentally through imaging or intra-operatively.
CASE PRESENTATION: A 63 year old female with no prior history of colonic diverticular disease
presented with an acute onset, severe, localized, left sided abdominal pain. Pain was associated with
emesis, constipation and a temperature of 38.3°C. Exam revealed decreased bowel sounds, left sided
abdominal tenderness and the absence of guarding or rigidity. Exam was otherwise unremarkable. Labs
revealed mild leukocytosis of 12.1 with neutrophilic predominance. CT was significant for acute jejunal
diverticulitis. A further small bowel follow through confirmed numerous jejunal diverticula. Given its
assciation with scleroderma, auto-antibody screen with ANA and Scl-70 had a negative yield.
Conservative management with NPO, intravenous fluids and ampicillin-sulbactam led to resolution of
symptoms within 48 hours.
DISCUSSION: We report a case of uncomplicated jejunal diverticulitis that resolved promptly with
conservative management. Uncomplicated JDD, precluding perforating events with peritonitis are best
managed with a trial of conservative management prior to surgical consideration. Pathogenesis of JDD is
suggested to result from small bowel motor dysfunction that can be associated with scleroderma. In
patients with history of scleroderma, JDD must be considered in the setting of GI symptoms. Autoantibody
screening can be recommended in undiagnosed patients. While the diagnosis of JVD is an
insightful finding, further management of uncomplicated JVD remains one of ‘watch and wait’ when the
general consensus places little value for surgical intervention. Chronic presentation of JVD can mimic
gastritis, peptic disease or irritable bowel syndrome. The role of screening with CT imaging is limited as
sensitivities for diverticula are marginal and can be missed as bowel loops or colon. The utility of postduodenal
endoscopy to rule out JVD in patients presenting with IBS associated features remains to be
determined.
501

PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Julio J Valentin, MD
Viral syndrome, a nearly lethal presentation
Julio Valentin Nieves, MD
INTRODUCTION:Leptospirosis is a zoonotic disease characterized by a spectrum of clinical
manifestations ranging from subclinical to fulminant, potentially fatal infection. Mortality is usually
associated to multiorgan failure. Cardiac disturbances range from ECG changes to overt myocarditis. In
the clinical setting, cardiac pathology is generally masked by overt pulmonary and/or hepatorenal
syndromes and therefore, overlooked or underestimated. In this case we see the initial an initial
presentation mimicking a viral syndrome that later progressed to cardiac complications, including ST
elevation miocardial infarction, miocarditis and acute respiratory distres syndrome.
CASE PRESENTATION: 31 year old man with history of traumatic brain injury who came to the
emergency room with a chief complaint of general malaise, unquantified fever, chills, myalgia, anorexia,
and nausea without vomiting of 3 days evolution, with associated headache, sore throat, and
nonproductive cough. Upon evaluation, he was found hypotensive, tachycardic, and febrile. Physical
exam was remarkable for dry oral mucosa, mild pharyngeal erythema, and bilateral conjunctival
suffusion. He recently traveled to the Dominican Republic. Initial labs were remarkable for leukocytosis,
thrombocytopenia, hyponatremia, elevated creatinine kinase, and normal bilirubin. He was admitted
with a diagnostic impression of viral syndrome and a working diagnosis of Dengue Fever. On hospital
day 1, after an episode of loss of consciousness (LOC), ECG demonstrated sinus tachycardia, with 2-4mm
ST elevation in anterior leads. Shortly after, he suffered a second episode of LOC accompanied by a selfresolving
polymorphic ventricular tachycardia (VT) resembling torsade de pointes. Despite adequate
management, he continued with chest pain and positive cardiac enzymes. Emergent coronary
angiography failed to reveal any obstructive lesions or vasospasm. Ventriculography showed mildly
reduced ejection fraction with segmental wall motion abnormalities. He persisted with episodes of nonsustained
VT, worsening dyspnea, and developed blood tinged sputum. Chest x-ray was remarkable for
bilateral confluent infiltrates, suggestive of alveolar hemorrhage. Clinical status continued to deteriorate
due to a 3rd episode of LOC and a 2nd recorded polymorphic VT that required defibrillation and IV
antiarrhythmics. The patient also required mechanical ventilation with protective lung parameters.
Diffuse alveolar hemorrhage was diagnosed by bronchoalveolar lavage. Broad-spectrum antibiotics were
started empirically. Work up for Influenza, Echovirus, Leptospira, Enterovirus, Coxsackie, Epstein-Barr
virus, Cytomegalovirus, and Dengue was sent. The patient’s clinical status dramatically improved.
Eventually convalescent antibody titers for leptospira were reported positive making leptospiral
myocarditis the likely diagnosis.
DISCUSSION: Leptospirosis is a zoonotic disease characterized by a spectrum of clinical manifestations
ranging from subclinical to fulminant, potentially fatal infection. Mortality is usually associated to
multiorgan failure. Cardiac disturbances range from ECG changes to overt myocarditis. In the clinical
setting, cardiac pathology is generally masked by overt pulmonary and/or hepatorenal syndromes and
therefore, overlooked or underestimated. Proposed mechanisms of arrhythmogenesis include
inhomogeneous repolarization and unstable membrane potentials in cardiomyocites secondary to tissue
inflammation. To our knowledge, there are no cases in the literature of anicteric leptospiral myocarditis
with coexistence of ST segment elevation-mimicking STEMI, polymorphic VT resembling torsade de
pointes, and diffuse alveolar hemorrhage with Acute Respiratory Distress Syndrome (ARDS) as
presenting entities. This case confirms the non-specific presentation of anicteric leptospirosis and
suggests that a high clinical suspicion along with early antibiotic therapy might prevent morbidity and
mortality.
502

PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Maryknoll De La Paz,
MD
A Breast Leukemia without an overt Bone Marrow Involvement
De La Paz-Maryknoll MD, Andino-Myrna MD, Gutierrez-Madeleine MD, Miranda-Mirelis MD, Solivan-
Pedro MD, Rivera-Caroline MD, Baez-Luis MD, Nieves-Dalila MD, Mendez-Angela MD
INTRODUCTION:Leukemia is a type of cancer of the blood or bone marrow (BM) characterized by an
abnormal increase of WBC's.
Medical literature has described rare tumors composed of a solid collection of leukemic cells with a
normal BM. One example is Extramedullary Myelogenous Leukemia (EMML) that are uncommonly seen
even by oncologists.
CASE PRESENTATION: A 36 year old nulliparous female with no systemic illness went to her physician
after she noted bilateral breast lumps on a self breast exam. Fever, night sweats or weight loss were
denied. Breast inspection showed her right breast bigger than the left and without skin lesions. During
palpation a 3cm nontender rubbery mass at the 2 o’clock position of the right breast and a1cm mass at
the 12 o’clock position of the left breast were identified. Nipple retractions, discharges
or lymphadenopathies weren’t evident. In the inspection of her lower back, 2 brown irregular skin
papules of 2 cm were identified. Breast studies revealed multiple complex nodules not present on
previous exams four years ago. Bilateral breast MRI showed numerous gadolinium ill
defined borders enhancing masses, too numerous to count. Biopsy of the right breast mass
demonstrated an EMMT positive for CD34, CD43, CD 117 and Ki 67 present in 60% of the cells, a
proliferation marker. Bone marrow biopsy (BMB) was negative for Acute Myeloid Leukemia (AML). She
was referred to MD Anderson Cancer Center and the diagnosis of EMMT was confirmed. The biopsy of
the skin lesions on her back was consistent with the diagnosis of Leukemia Cutis. After induction
chemotherapy the breast lesions were not palpable and the papules on her back decreased in size.
DISCUSSION: An EMMT is composed of immature myeloid precursor cells. There are many body
presentations but breast involvement occurs in only 6% of cases. The symptoms are related to the
anatomical localization but also can be incidentally found in asymptomatic patients. This type of tumor
is easily misdiagnosed as a lymphoma or fibrocystic breast disease, making the diagnosis a real
challenge. The successful approach to the patient’s clinical presentation is based on the early suspicion
of a rare but possible diagnosis. The last BMB concluded that her BM is free of disease 13 months after
the diagnosis, even though the mean to develop BM AML is 8 months. To our knowledge, there are
only 4 case reports free of BM disease after 13 months or more of the EMMT diagnosis. We have
diagnosed case number 5.
503

PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Victor J Mariano, MD
A RARE CAUSE OF RAPIDLY PROGRESSING PNEUMONIA IN A YOUNG PATIENT
Victor J Mariano, MD second Author: Juan Vázquez, MD Third Autho: Rodrigo Valderrabano, MD
INTRODUCTION: Recurrent sinopulmonary infection is the most common illness associated with IgA
deficiency (IgAD) patients. Most upper and lower respiratory tract infections are caused by bacterial or
viral pathogens characteristic of community-acquired pneumonia.
CASE PRESENTATION: A 33 year-old woman arrived at our Emergency Department after having been
woken from sleep at 4:00am with complaints of shortness of breath, dry cough and right sided chest
pain that increased with breathing. ABG’s ordered in the E.D. revealed an oxygen saturation of 90%,
PaO2 at 67mmHg and a PaCO2 at 29 mmHg, the chest radiograph revealed a right lung base mild opacity
that could be interpreted as “Hampton hump”. These findings in conjunction with a history of right foot
orthopaedic surgery 2 weeks before developing symptoms and the sudden nature of disease
progression led us to the working diagnosis of pulmonary embolism (P.E.). A spiral CT scan was ordered
but revealed right lower lobe pneumonia instead of the characteristic findings of P.E. A second CT scan
performed in 48hrs as per radiologist’s recommendation showed progression to a bilateral lower lobe
pneumonia.
DISCUSSION: Our patient’s initial presentation although typical of a P.E. was instead the result of a
pneumonic process. Rapid progression to a bilateral pneumonia was however uncharacteristic of this
patient’s age group. Further history revealed sinusitis since the patient was 9 years old twice per year
until she turned 18, a hospitalization for pneumonia at age 24, 3 episodes of bronchitis the last one at 30
years old and a recent diagnosis of ulcerative colitis. This added past medical history was suspicious for
an immunoglobulin deficiency. Immunoglobulin levels were ordered on two different occasions four
weeks apart and results showed IgA level less than 15 on both tests, which is the lowest possible
reference value on that particular laboratory. The diagnosis of IgA deficiency was made.
Immunoglobulin deficiency although not common, must be always scrutinized in patients with recurrent
infections and prior history of autoimmune diseases. This case is an example of the importance of
establishing a wide differential diagnosis in cases with recurrent infections.
504

PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Azar Sadeghalvad, MD
From Bee Sting to Acute Kidney Injury and Rhabdomyolysis.
Azar Sadeghalvad, MD, Francisco Jaume-Anselmi, MD, FACP, Amaury Segarra, MD, José Ramírez-Rivera,
MD, MACP,
INTRODUCTION: Africanized bees are spreading over the American hemisphere since they were
accidentally released in Brazil 5 decades ago, and were introduced to Puerto Rico in 1994. Their massive
attacks can cause less common nonallergic multi-system involvement ranging from rhabdomyolysis and
acute renal failure.
CASE PRESENTATION: An 86-year-old healthy farmer, a retired physician, experienced massive bee
stings attack after he accidentally disturbed an Africanized bee colony, and was found on the ground 1.5
hr later. On admission, he was conscious, mumbling due to facial and buccal edema with diffuse body
aches, without loss of bladder or bowel control. The T was 35.7 º C, RR 16, P 96, and BP 161/87. There
were over 400 bee sting marks on his head, and neck. There was bilateral periorbital, auricular, and
buccal edema, with many bee stings inside his mouth. The leukocyte count was 18.5 (N 86, L 1, B 12, M
1), Hb 15.7, Hct 45.9%, and Plt 151,000. The Glucose was 92, sodium 138, K 4.3, Cl 106, HCO3 20, BUN
31and Cr 2.1. An arterial blood sample (100% FIO2) showed pH 7.38, PCO2 39.5, HCO3 24, PO2 133 and
SaO2 100%. The ECG, chest film, head CT, and renal ultrasound were within normal limits. He was
treated with Solumedrol 125 mg IV, Benadryl 50 mg IV, 0.9 NSS 100 ml/hr, and epinephrine 1mg IM,
with a meticulous effort to remove all stings. He was admitted with systemic inflammatory response
syndrome, due to massive bee stings. He was continued with Zosyn 2.25 gr IV q 6 hr, Solumedrol 80 mg
IV q 8 hr, Benadryl 50 mg IV q 8 hr, and normal saline at 150 ml/hr. Four hours after admission, CPK was
5,034 U/L, BUN 10, Cr 0.84 and the urinalysis showed large blood, moderate RBC, and few granular
casts. Fourteen hours after admission, BUN, Cr, and CPK had increased to 67, 4.5, and 13,108
respectively. A urine myoglobin of 7,950 mcg/L confirmed rhabdomyolysis. Aggressive volume
replacement followed by Lasix, Mannitol, and HCO3 drip did not produce any diuretic response. The
chest radiograph showed congestive changes with bilateral pleural effusions, and hemodialysis (HD) was
initiated. He was discharged after 8 days with a Cr of 7.1, and a CPK of 1,642. HD was required for 1
month.
DISCUSSION: Clinicians need to be aware that anyone who experiences massive bee envenomation
requires close observation, even if they appear to be well, as rhabdomyolysis and renal failure
can present after 24 hours. Serum CPK, liver, and renal function must be monitored. Aggressive volume
replacement is required to protect kidney function.
505

RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Ross W Hilliard, MD
Microscopic Polyangiitis: A Unique Opportunity to Observe Disease Onset and Initial Progression Over
the Course of One Inpatient Admission
Ross W. Hilliard, MD Second Author: Mark Hepokoski, MD Third Author: Sarita Warrier, MD Fourth
Author: Michael Maher, MD
INTRODUCTION: ANCA associated rapidly progressive glomerulonephritis (RPGN) is a disorder with
significant morbidity that often presents with end stage renal disease. We present a case of a patient
with previously undiagnosed microscopic polyangiitis (MPA) and a normal creatinine on hospital
admission who subsequently developed RPGN requiring pulse dose steroids and cyclophosphamide
therapy during his stay.
CASE PRESENTATION: A 68 year-old gentlemen from the Dominican Republic presented to our
hospital with the chief complaint of recurrent rectal prolapse. This was reduced in the Emergency
Department, but the patient was admitted after he was incidentally found to have a fever and white
blood cell count of 21,000. The patient’s only other complaint on admission was general malaise. His
exam at the time of admission revealed no skin, joint, cardiac, or pulmonary abnormalities. Over the
course of 11 days, an extensive infectious work-up for his fever and leukocytosis was conducted,
including blood cultures, urine cultures, chest radiography, and serologies for tick-borne illnesses, fungal
species, and tuberculosis, all of which were unrevealing. Finally, on hospital day 12, an ANCA screen
revealed a positive pANCA with high positive myeloperoxidase antibody and normal proteinase 3
antibody. Over the next two hospital days he developed worsening renal failure with dysmorphic red
cells in his urine sediment. He then underwent renal biopsy which showed a crescentic
glomerulonephritis with crescents in over 50% of his glomeruli. This confirmed the diagnosis of RPGN
secondary to MPA. Methylprednisolone was initiated while biopsy results were pending, and
cyclophosphamide was added afterward. The patient’s creatinine peaked at 2.84 mg/dl from 1.0 mg/dl
on admission, and improved to 1.9 mg/dl two weeks after discharge.
DISCUSSION: MPA is a relatively rare autoimmune condition involving arterial damage that can affect
multiple organ systems, including respiratory, renal, and more rarely cardiac, nervous and GI
systems. The initial symptoms are usually vague malaise, myalgias, and fevers, as was the case with our
patient. In many instances, patients present only after significant end-organ damage has already
occurred. This is more often the case with renal involvement where patients present after noting
hematuria, edema, or dyspnea from volume overload. In fact, a University of North Carolina study
showed that the average serum creatinine of patients presenting to their institution with this disorder
was 6.5 mg/dl. Our patient, with no findings of vasculitis on admission, developed crescentic
glomerulonephritis from MPA two weeks into his hospital stay. We believe that the patient’s early
presentation allowed the diagnosis and treatment of this severe disorder to occur much earlier than
expected, thus allowing for more significant renal recovery.
506

RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Elizabeth Ko, MD
Can’t See, Can’t Hear, Can’t Walk
Elizabeth Ko, MD and Diana-Frances Coffie, MD
INTRODUCTION: Cogan syndrome is a rare autoimmune condition characterized by inflammation of
the cornea and vestibuloauditory system.
CASE PRESENTATION: Mr. MH is a 37 year-old healthy gentleman who presents to the emergency
department with a one-month history of progressively worsening eye irritation, hearing loss and
disequilibrium. His symptoms began with blurry vision and extreme photophobia. He saw no
improvement with prescription antibiotic eye drops. One morning, he felt dizzy, nauseous and unsteady
on his feet. He also noticed gradual hearing loss. A head CT scan was unremarkable, and a neurologist
recommended a brain MRI and ENT referral. One week later, he returned to the ED for unrelenting
symptoms. He had lost hearing in his left ear and his right ear responded only to very loud sounds. Over
this period, Mr. MH reported a 15-pound weight loss and a diffuse infra-orbital headache; he denied
fevers, joint aches, urethral discharge or skin rashes.
On exam, Mr. MH is afebrile, blood pressure 124/68, pulse 68. He is a well-built gentleman, in distress,
who is speaking clearly and fluently in a booming voice. He has extensive tearing and conjunctival
injection with hazy corneas. Pupils are sluggish but reactive. Tympanic membranes are clear. Bone
conduction is greater than air conduction bilaterally without Weber lateralization. Cardiovascular and
pulmonary exam are unremarkable. Visual acuity is 20/30 in the right eye and 20/80 in the left eye.
Strength is 5/5 in all extremities, sensation is intact to light touch and he has no dysmetria. He has an
ataxic gait and a positive Romberg’s sign. Laboratory data include a normal CBC, normal BMP, ESR 37,
CRP 23. Autoimmune serology include normal C3, C4, and negative ANA, ANCA, ds-DNA, SS-A, SS-B,
cryoglobulin, RPR, lyme. Hsp-70 (anti-KD 68 antigen) was negative. A head and neck MRI/MRA showed
no evidence of vasculitis.
Mr. MH was admitted to the medicine service for these constellation of symptoms which define Cogan
syndrome. Slit lamp exam confirmed interstitial keratitis. An audiometry evaluation was revealing for
moderately-severe sensorineural hearing loss on the right and profound loss on the left. Mr. MH was
treated with salumedrol IV and prednisolone eye drops. His visual acuity improved, his hearing
recovered and he no longer required a cane to walk.
DISCUSSION: The treatment of Cogan syndrome, which includes high-dose steroids, is a common
approach towards an otherwise uncommon condition marked by ocular inflammation and
vestibuloauditory dysfunction. Mr. MH’s story is a heroic account of a vulnerable inmate with no means
of communication, who responded beautifully to a course of steroids, and has emerged as a confident
gentleman who can now see, hear and walk.
507

RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Michele Therese L
Yamamoto, MD
Klebsiella In My Joint : A Case Of Klebsiella Pneumoniae Septic Arthritis
Michele Therese L Yamamoto MD; Michael C Agustin MD; Teresa Slomka MD; John P Miskovsky MD;
Marguerite Neill MD.
INTRODUCTION:Staphylococcus aureus and Streptococci are predominant pathogens causing septic
arthritis of native joints. We report a case of septic arthritis caused by Klebsiella pneumoniae for which
there are a few published reports.
CASE PRESENTATION: An 88-year old man was admitted with fever and mild confusion after a fall
from his chair. Three weeks earlier he was hospitalized for possible community acquired pneumonia
treated with Moxifloxacin. One week later, he developed right shoulder pain. Past medical history
includes ischemic cardiomyopathy with biventricular pacing defibrillator, chronic kidney disease after a
nephrectomy and IVC filter for a pulmonary emboli. On physical exam, he was lucid and febrile. His right
shoulder was tender to palpation without erythema and had limited range of motion. Vancomycin and
Ceftriaxone were started. CT scan showed a chronically torn rotator cuff and severe degenerative joint
disease with no evidence of fracture or joint effusion. Intra-articular steroid injection was planned. As
the local anesthesia was about to be injected, an aspirate of the joint fluid returned 15cc of purulent
fluid which immediately clotted. There were sheets of neutrophils but no organisms on gram stain.
Calcium pyrophosphate crystals were noted. Both blood and joint cultures yeilded Klebsiella
pneumoniae. Urine analysis and urine culture were negative. Arthroscopic incision and drainage was
done and the patient defervesced with improvement of shoulder pain. Removal of the cardiac device
was not feasible and a 6-week course of intravenous Cefazolin was instituted. At 4 weeks of follow-up,
the patient is doing well without systemic signs of infection, negative blood cultures and improving
range of motion of the joint.
DISCUSSION: Current English literature identifies only 19 reported cases of Klebsiella pneumoniae
septic arthritis. Risk factors include chronic underlying disease such as diabetes, liver and chronic renal
disease, malignancy and HIV. Most cases arise from hematogenous transmission from distant sites of
infection such as respiratory, gastrointestinal and urinary source. Treatment includes joint incision and
drainage and parenteral antibiotics. Klebsiella pneumoniae strains are usually susceptible to
Cephalosporins but those that produce an extended spectrum beta-lactamase require Carbapenem
therapy. Poor outcomes are observed in patients with pre-existing joint disease, prosthetic joints and in
those whom incision and drainage is not done. Although enteric bacilli account for less than 25% of
septic arthritis, antibiotic coverage for these pathogens should be included initially in cases of septic
arthritis, particularly when the gram stain of joint fluid is negative and the patient is
immunocompromised. Early and appropriate antibiotic treatment and surgical debridement strongly
contributed to the successful outcome of this patient's infection.
508

SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Ashley N Latos, MD
lemierre’s Syndrome: An Uncommon Complication Of A Common Condition, Ashley N. Latos, Md,
Associate, Department Of Medicine, Medical University Of South Carolina, Charleston, Sc
Ashley N Latos, MD
INTRODUCTION: Lemierre’s Syndrome is a condition characterized by septic thrombophlebitis and
bacteremia, often associated with the bacteria Fusobacterium necrophorum. Although a rare condition,
it often follows common oropharyngeal infections such as tonsillitis and dental infections. Its
complications include septic pulmonary emboli that can lead to hypoxemia, empyema and lung
cavitation.
CASE PRESENTATION: A 19-year-old Hispanic male with no past medical history presented with five
days of malaise, fevers and hemoptysis that were preceded by a sore throat. Initial work-up revealed a
fever of 103.5, WBC 18.6, platelets 24, D-dimer >500 and elevated ESR and CRP. Liver function tests
were also elevated as well as total and direct bilirubin. CT scan was negative for pulmonary embolus but
revealed numerous cavitary nodules bilaterally, concerning for septic emboli, as well as consolidation in
the lower lobes bilaterally, concerning for pneumonia. Physical exam was notable for jaundice,
tachycardia, decreased breath sounds in bilateral lung bases as well as crackles in the left lower
lung. Doppler Ultrasound revealed a left internal jugular vein clot. His initial anaerobic blood culture
bottle grew Fusobacterium necrophorum. A diagnosis of Lemierre’s syndrome was made and
appropriate antibiotics were initiated. He developed acute hypoxic respiratory failure, requiring 10L of
oxygen via nasal cannula and eventually an oximizer. After continued supportive treatment and
appropriate antibiotic therapy, his symptoms improved. He was eventually transitioned to oral
antibiotics and completed a treatment duration of 6 weeks.
DISCUSSION: This case illustrates a potential serious complication of a relatively simple condition,
tonsillitis. Although a rare complication, Lemierre’s Syndrome is associated with common conditions
seen by many primary care physicians. It is characterized by septic thrombophlebitis and bacteremia,
and often follows common oropharyngeal infections such as tonsillitis and dental infections. It is most
commonly associated with the bacteria Fusobacterium necrophorum and can cause serious
complications, such as septic pulmonary emboli, leading to hypoxemia and respiratory failure. With the
potential for such significant sequelae, it is imperative, therefore, that primary care physicians keep this
diagnosis in mind when evaluating patients that present with more systemic and severe symptoms
following an initial presentation with what may seem like a simple sore throat.
509

SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Nathan Richards,
MD
An Atypical Case of Acute Pericarditis
Nathan Richards, MD Second Author: William Edwards, MD Co-Author: Brad Keith, MD
INTRODUCTION: Learning Objectives:
1) Discuss clinical presentation and diagnostic evaluation of acute pericarditis
2) Discuss etiologies of acute pericarditis with specific discussion mesalamine induced pericarditis
3) Discuss treatment and prognosis of acute pericarditis
CASE PRESENTATION: 28 y/o female with past medical history significant for recently diagnosed
ulcerative colitis who presented to the ED twice over 1 week period for recurrent left sided chest pain.
Her pain was described as a 10/10 sharp sensation, sudden in onset, worse when supine, and improved
with leaning forward. The pain radiated to her left scapula. Her physical exam was only remarkable for
tachycardia and no murmurs or rubs were present. On presentation the patient had an EKG revealing
diffuse ST elevations. Work-up revealed RF, ANA, ANCA negative; HIV1/HIV2 negative; CMV negative;
Hgb was 7.4 with MCV of 70; Fe 8.0; Transferrin 168; Fe/TIBC %saturation 3%; Hgb variants normal. An
ECHO demonstrated a small to moderate circumferential pericardial effusion. The patient was again
given the diagnosis of acute pericarditis and continued on colchicine and Ibuprofen. Mesalamine was
restarted 3 weeks prior to symptoms and the dose was increased 1 week prior from 3.6grams to 4.8
grams. In literature review, mesalamine has been reported to be a rare cause of pericarditis, and this
was felt to be the culprit given the recurrence of her symptoms.
DISCUSSION: Acute pericarditis is an inflammation of the pericardial sac and often adjacent
myocardium. Chest pain is the predominate feature, classically presenting as sudden, sharp retrosternal
or left sided chest pain often radiating to the back. The pain is usually exacerbated in the supine position
and partially relieved when leaning forward. Physical exam may reveal a pathognomonic pericardial
friction rub, but is often unrevealing. Serial EKGs are often obtained showing an evolution of signs, of
which, only stage 1 is specific for pericarditis demonstrating diffuse ST-segment elevations with PR
depression. Echocardiography may reveal a small pericardial effusion. The cause is usually not identified
but most cases are thought to be viral in origin. Other etiologies to consider are uremia, post myocardial
infarction, collagen vascular disease, cancer, and drug induced. The list of medications that have been
associated with pericarditis is extensive but includes procainamide, hydralazine, amiodarone, Isoniazid,
Penicillin, cyclophosphamide, and mesalamine. The disease is usually self-limited and typically responds
well to NSAIDs, with a common regimen being ibuprofen 400-800mg Q8 hours for 2 weeks. Colchicine
may also be beneficial especially in cases of recurrent pericarditis. Mesalamine induced pericarditis is a
rare phenomenon but there have been multiple case reports of recurrent myopericarditis in the setting
of mesalamine use which resolved completely once the medication was stopped.
510

SOUTH DAKOTA POSTER FINALIST - CLINICAL VIGNETTE Muhammad A Khan,
MD
Hyperhemolysis Syndrome in a patient with Adenocarcinoma of the colon.
Khan, Muhammad. Ghanta, Bhargavi. Darabi, Kamran.
INTRODUCTION: Delayed hemolytic transfusion reaction (DHTR), is a well known complication of
transfusion therapy. Occasionally, native red cell hemolysis can be implicated in DHTR resulting in lower
post transfusion hemoglobin than pre transfusion. This condition, termed as hyperhemolysis syndrome,
is more common among patients with sickle cell disease and thalassemia. The occurrence of this
syndrome in patients without underlying hemoglobinopathies is rare.
CASE PRESENTATION: A 74 yr old female with prior history of colonic adenocarcinoma presented to a
local hospital with diarrhea. She was found to be anemic with hemoglobin of 8.4 g/dl. Her blood group
was A negative and she received 2 units of cross matched red blood cells after a negative antibody
screen. She returned to the hospital 12 days later with lethargy and fatigue and was found to be anemic
with hemoglobin of 7.8 g/dl. Antibody screen was positive for Anti-K antibody. Hemolysis persisted
despite receiving K antigen negative red blood cells and twice during the following 30 day period, her
hemoglobin decreased to a level lower than her initial value. No source of bleeding could be identified
and a normal hemoglobin electrophoresis was noted. She responded well to 4 weeks of oral prednisone
with no further hemolysis after discontinuation of therapy.
DISCUSSION: Hyperhemolysis syndrome can occur in patients with no underlying hemoglobinopathies
and oral prednisone is an effective treatment.
511

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Ahmad Lutfi Alazzeh, MD
"NOT QUITE an ACUTE ST-SEGMENT ELEVATION MI"
Ahmad Alazzeh MD; Venkat Gangadharan MD; Terry Forrest MD FACC; Clarence Spannuth JR MD ;
INTRODUCTION:Acute Myocardial Infarction is one of the most serious emergencies physicians face on
a daily basis. The typical presentation includes chest pain with classic EKG changes and positive
TROPONIN level. However, rarely with these findings there is an alternative etiology
CASE PRESENTATION: A 58 year old man presented to the ER with complaints of worsening chest pain.
His past medical history included a previous myocardial infarction, and diffuse large B cell lymphoma
treated with 6 cycles of R-CHOP with remission. Physical Exam revealed a patient in moderate distress
secondary to chest pain, slightly elevated blood pressure and HR, right testicular swelling, but no chest
wall tenderness. labs revealed a normal CBC and BMP, but marginally elevated troponin I (1.3).
Subsequent EKGs demonstrated 1-2 mm concave ST elevation. With chest pain, history of anteroseptal
MI, and other risk factors for CAD including family history and tobacco abuse. Patient was evaluated by
left heart catheterization, which revealed mild nonobstructive coronary artery disease. With these
results, possible anterior ST elevation MI was ruled out and further investigations were carried out
including a Transthoracic ECHO demonstrated a unique finding of profound anteroseptal wall thickening
resulting in near obliteration of the left ventricular cavity with marked reduction in LV function. CHEST
CT revealed multiple enlarged mediastinal lymph nodes suggestive of a recurrence of his previous Non-
Hodgkins Lymphoma. With his clinical picture and radiological findings the likely etiology of his chest
pain, elevated troponin and evolving EKG changes were attributed to secondary cardiac lymphoma – a
rare manifestation.
DISCUSSION: Metastatic involvement of the heart is more common cause of cardiac malignancies;
therefore cardiac or pericardial metastasis should be considered whenever a patient with a known
malignancy develops cardiovascular symptoms. Malignant melanoma, leukemia, lymphoma, lung and
breast cancers are most commonly associated with cardiac involvement. Most cases of cardiac
lymphoma demonstrate either one or more chamber involvement with the right heart being the most
common site. Hypertrophy or thickening of the ventricular septum, can result in characteristic
hemodynamic disturbances. Clinical symptoms of cardiac lymphoma are nonspecific ranging from being
silent (as seen in B cell lymphomas ) to producing chest pain, worsening shortness of breath,
palpitations etc. Physical signs may include a pericardial friction rub; distended neck veins or even signs
of heart failure. Diagnostic evaluation should mainly include echocardiography, MRI and CT. Most often,
however, conclusive diagnosis via tissue sampling is usually obtained on post-mortem
examination. Conclusion: Cardiac Lymphoma, albeit a rare disease, can mimic acute ST-Elevation
Myocardial Infarcation. Early detection and treatment of Cardiac Lymphoma in cases of recurrent Non-
Hodgkin Lymphoma is imperative to prevent serious complications such as outflow obstruction and to
develop therapeutic regimens in the future
512

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Matthew Erickson
Edwards, DO
Acute Psychosis in a Patient with Cushing's Disease
Matthew Erickson Edwards, DO Mark Rasnake, MD, FACP Daphne Norwood, MD, FACP
INTRODUCTION: Cushing’s syndrome is a rare endocrine disorder that causes increased secretion of
cortisol through disruption of the hypothalamic-pituitary-adrenal axis. This occurs in either an
adrenocorticotropic hormone (ACTH) dependent or ACTH-independent mechanism. Cushing’s syndrome
impacts multiple organ systems and can have a variety of manifestations. Acute psychosis is a less
common but documented manifestation of Cushing’s syndrome.
CASE PRESENTATION: A 57-year-old Caucasian male presented as a direct admit to the impatient
service from his primary care office with acute psychosis and delirium. He was a successful, high
functioning individual until he began experiencing spells of paranoia, hallucinations, hyper-sexuality, and
seizure-like activity over the previous 3 weeks. The episodes were increasing in frequency and
severity. He had been diagnosed with Cushing’ syndrome two years prior and the exact etiology had not
been identified. He was undergoing treatment with metyrapone. There was no history of substance
abuse or psychiatric illness.
Vital signs revealed the following: temperature 98.0°F, BP 142/90 mmHg, HR 66, RR 20, and
oxygen saturation 95%. Physical exam was notable for findings characteristic of Cushing’s syndrome.
Neurologically he had no focal deficits and was alert and oriented to person, place, and time. Psychiatric
evaluation revealed paranoid and grandiose thoughts with no intention to harm others or self.
Extensive serological studies were remarkable for mildly elevated prolactin and chromogramin A
levels. Cortisol level was normal, however outpatient records indicated recent elevation, as well as ACTH
elevation. Toxicology screen was negative. CT and MRI of the head and neck were notable for a stable
right frontal lobe cavernous malformation. CT of the chest, abdomen, and pelvis was negative for any
significant abnormality. EEG demonstrated no signs of epileptiform activity.
After exclusion of other causes, it was thought that his acute psychosis could be a manifestation
of Cushing’s syndrome. He was started on antipsychotics for symptom management and referred to an
outside facility for further evaluation including inferior petrosal vein sampling and pituitary MRI. This
revealed a pituitary adenoma secreting ACTH, specifying this as Cushing’s disease, and resection of this
lesion is pending. He is still experiencing episodes of abnormal behavior but is hopeful surgery will be
curative.
DISCUSSION: The neuropsychiatric manifestations of Cushing’s are less common but nonetheless
debilitating. The severity can range from anxiety to psychosis, with major depression being the most
common manifestation. Previous case reports note that the neuropsychiatric complications of Cushing’s
improve with treatment but some patients never return to baseline function.
513

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Hetvi K Joshi, MD
SHAKY HEART CAN PRESENT AS SHAKY LIMB
Hetvi K Joshi, MD Second Author: Nathaniel Whaley MD Third Author: Mihir Patel MD
INTRODUCTION:Transient Ischemic Attack (TIA)and stroke not uncommonly occurs secondary to focal
cerebral hypoperfusion in the context of relative hypotension distal to an extra or intracranial artery
stenosis.In this report,we document a case of an unusual presentation of TIA known as a shaky limb TIA
in the context of carotid occlusion and decreased ejection fraction(EF)secondary to symptomatic
advanced coronary artery disease(CAD).
CASE PRESENTATION: A 57 Year old male presented with chest pain and recurrent left hemianesthesia
who described 3 month history of near weekly episodes of brief transient left arm and leg involuntary
jerking, shaking with retained awareness that occurred only with standing and often resulted in a fall. He
had a history of recurrent right middle cerebral artery (MCA)territory ischemic stroke,total right internal
artery carotid (ICA) occlusion and an extensive history of CAD status post coronary artery bypass graft
(CABG) with EF of 15 %. Computed tomography (CT) angiogram of the extra cranial vessels confirmed
total occlusion of the right ICA and 70% stenosis of right vertebral artery.A CT head showed evidence of
old right frontal and parietal lobar strokes.The individual was taken for cardiac catheterization which
confirmed an occluded graft to the left anterior descending and severe native multi-vessel CAD. He
underwent percutaneous coronary intervention(PCI)for the same.After that chest pain and shaky limb
symptoms resolved.
DISCUSSION: Limb shaking TIA is rare phenomenon.It is likely under recognized by primary care
physicians because of its positive symptomatology (i.e. increase in movement) whereas stroke or TIA is
most commonly associated with negative symptoms (i.e. loss of function).The mechanism behind this,is
transient hypoperfusion of the motor areas of the cerebrum(i.e. precentral gyrus) usually in the context
of relative hypotension in the setting of an ICA stenosis resulting in partial dysfunction making the limb
shake.The principal of management is to avoid hypotension and increase perfusion to the ischemic
area.In this case,cardiac intervention was performed in an attempt to increase the cardiac EF and to
optimize the individual’s medical management in order to avoid hypotension. If these measures prove
ineffective,an extracranial-intracranial bypass may be considered.
514

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Adrianne C Netterville,
MD
Infected Left Atrial Myxoma, a Rare Cause of Bacteremia with a Common Pathogen
Adrianne C Netterville, MD Second Author: Mark S Rasnake, MD
INTRODUCTION: Bacteremia due to methicillin resistant Staphylococcus aureus (MRSA) is very
common, but rarely is the etiology from an infected left atrial myxoma. Myxomas are the most common
primary cardiac tumor. Uninfected myxomas often mimic endocarditis clinically and large vegetations
from endocarditis have been known to mimic myxomas. Infected myxomas themselves are quite rare
however. If presented with persistent positive blood cultures or fever of unknown origin, a patient
should always be evaluated with echocardiography to rule out endocarditis or, as in our case an infected
myxoma.
CASE PRESENTATION: A 68- year-old male originally was admitted to an outside hospital to undergo
an elective left hip arthroplasty. Subsequently, his post operative course was complicated by ileus and
hematochezia. He underwent an EGD, which showed gastritis. He gradually improved postoperatively
and was transferred to a rehabilitation facility. He continued to improve at the rehab hospital until he
spiked a fever and was found to have 2/2 blood cultures positive for MRSA. Vancomycin was initiated.
On day ten of antibiotics, he developed another fever and was again found to have 2/2 blood cultures
positive for MRSA. Vancomycin was switched to linezolid. Transesophageal echocardiogram suggested
vegetations and he was therefore transferred to our facility for surgical evaluation. Repeat
echocardiogram showed a left atrial mass adherent to the interatrial septum. He then underwent
robotically assisted removal of the left atrial mass. While in the operating room, they performed frozen
sections which were microscopically and grossly consistent with a myxoma. A calretinin immunostatin
was performed and highlighted the myxoma cells. Following surgery repeat blood cultures showed no
growth. He was treated with a six week course of daptomycin and was well at his two month follow up
visit.
DISCUSSION: This case illustrated an unusual cause of persistent bacteremia. Infected myxomas are an
extremely rare entity. The most common presentations mimic infective endocarditis with fatigue,
malaise, and weight loss. Fevers are also common even in uninfected myxomas. Embolization with
uninfected atrial myxomas is very common, although once infected, the incidence of cerebral and
systemic embolization is much higher. The most common cause of infected atrial myxomas is dental
work. In our patient, it is believed to have become infected via bacteremic seeding during prior hip
arthroplasty.
Evaluation should include echocardiography and prompt surgical resection in order to reduce the
chances of embolization or cardiovascular complications, including sudden death. Patients should also
undergo annual surveillance with echocardiography, to monitor for recurrence.
515

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Pranav B Patel, MD
The Wolf in Sheep's Clothing
Pranav B Patel, MD Co Authors: Tejas Raiyani, MD Atul Khanna, MD Mark Young, MD
INTRODUCTION: Colon cancer is the most common gastro-intestinal malignancy. It is the third most
common form of cancer and second leading cause of death among cancers worldwide. Colon cancer
commonly presents as bleeding, ill-defined abdominal pain, altered bowel habits or intestinal
obstruction. It rarely presents as Psoas abscess. Diagnosis remains difficult, especially when it is the first
sign of colon cancer. We report a case of colon adenocarcinoma presenting as Psoas abscess.
CASE PRESENTATION: A 65 years old woman presented with swelling and erythema over right gluteal
region 48 hours after intramuscular injection of Ketorolac for arthritic hip joint pain. She also
complained of constipation with abdominal discomfort for two weeks. She had induration over the right
gluteal region with diffusely tender abdomen. Laboratory data showed leukocytosis, elevated ESR, Hg of
9.3gm%, low MCV at 76fl and low ferritin at 15ng/ml. Stool hem-occult was negative. Ultrasound of
abdomen and right buttock demonstrated extensive edema without distinct abscess in gluteal region.
Empiric antibiotics were started. After two days, purulent discharge was noted from right gluteal region.
Computed Tomography (CT) of abdomen and pelvis showed right psoas abscess with air pockets.
Surgical debridement was performed. Wound culture grew E. coli and anaerobes. Biopsy of the abscess
wall showed necrotic tissue with no evidence of malignancy. Her course was further complicated with
venous thrombo-embolism (VTE), for which heparin was started. She developed hematochezia while on
heparin. Gluteal wound failed to heal and repeat CT showed persistent retroperitoneal abscess
extending up to right groin with thickened cecal wall. She underwent another exploration of local area
with debridement. Right groin had necrotic lymph node on exploration. Excisional biopsy showed
adenocarcinoma believed to be of colon origin. On colonoscopy a large multi-lobulated cecal mass was
found and biopsied. Moderately differentiated adenocarcinoma of colon was confirmed on pathology.
Patient underwent right hemicolectomy and adjuvant chemotherapy was initiated.
DISCUSSION: Colon adenocarcinoma is one of the few preventable and curable cancers if detected and
treated in time. Psoas abscess is a rare presentation of colon adenocarcinoma. There are very few
reported cases in literature which suggest colon cancer as possible etiology in unexplained psoas
abscess. It is very likely that colon cancer was already present in our patient at the initial presentation of
the psoas abscess. Presence of iron deficiency anemia, constipation and abdominal discomfort in our
patient could have led us to consider colonoscopy at early stage but co-incidental history of
intramuscular injection prior to onset of symptoms clouded the diagnosis initially. However, failed
response to treatment, repeat CT scan findings and tissue biopsy guided us towards colonoscopy, which
confirmed the diagnosis. In Conclusion, our case highlights the importance of considering underlying
colon cancer in patients with psoas abscess and colonoscopy should be considered at early stage to
resolve the diagnostic dilemma.
516

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Devon Paul, MD
Idiopathic Pulmonary Fibrosis, Or Something More? What Families Teach Us About The Disease.
Devon Paul, MD
INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease (ILD) characterized by
replacement of normal lung parenchyma with fibrotic tissue, leading to respiratory failure in half of
patients within three to five years of diagnosis. It has an estimated prevalence of 42 cases per 100,000
people in the US. The disease progresses at variable intervals, is ultimately fatal, and has no effective
medical treatment. Recent advancements in IPF research have led to the discovery that a significant
proportion of cases are familial. In studying familial IPF cohorts, multiple gene mutations
have been identified linking IPF to other inheritable diseases, providing insights into the pathogenesis of
the disease while offering potential targets for therapy.
CASE PRESENTATION: A 61 year old male presented to his primary care physician at the urging of his
family complaining of dyspnea with exertion. He had an extensive family history of IPF. He was referred
to a pulmonologist, where he underwent pulmonary function testing (PFT) which showed restrictive
lung disease and decreased diffusion capacity (DLCO). A high-resolution computed tomography (HRCT)
scan of his chest showed bibasilar fibrosis with honeycombing in a usual interstitial pneumonia
pattern. He was diagnosed with IPF and referred to a tertiary medical facility, where he was enrolled in
a phase three clinical trial. Since his diagnosis of IPF, his daughter has also been screened, and was
found to have early pulmonary fibrosis on HRCT in addition to known leukopenia and anemia. Detailed
family history revealed multiple maternal family members with IPF, cryptogenic cirrhosis, or
myeloproliferative disease. Given his pedigree, he and his daughter have both agreed to genetic testing
to see if their family possesses a known familial IPF gene mutation.
DISCUSSION: This patient's case illustrates key points about IPF pertinent to the general internist. First
is the recognition that the disease is more common that originally believed. Many primary care
physicians will have IPF patients in their clinic at some point in their careers. Second, up to 20% of IPF
cases are familial. For the primary care physician seeing family members of IPF patients, knowing this
association is critical. Third, among familial IPF cases, several genetic mutations have already been
identified. The most significant of these are the TERT and TERC mutations in the telomerase complex,
found in approximately 15% of familial IPF cases. Families with these mutations often exhibit a
spectrum of disease including IPF, myelodysplastic syndrome, aplastic anemia, cirrhosis, and
dyskeratosis congenita. The multidisciplinary nature of internal medicine allows internists to identify
linkages between disorders such as these in disparate organ systems, and will be critical as more cases
of IPF are discovered.
517

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Tejas Vinodbhai Raiyani,
MD
Dysphagia – Roots Laid in Coronaries !!!
Tejas Vinodbhai Raiyani, MD Co Author: Pranav Patel, MD Co Author: Vijay Ramu, MD
INTRODUCTION: Dysphagia has been a common symptom related to upper gastrointestinal system. It
has rarely been reported related to cardiovascular system. Coronary Artery Disease (CAD) causing
dysphagia has not been reported in the literature. We report a case of severe multi-vessel CAD that
presented as dysphagia which resolved completely after Coronary Artery Bypass Grafting (CABG)
procedure.
CASE PRESENTATION: A 80-year-old woman with history of dyslipidemia presented with difficulty to
swallow solids and liquids on and off for one year with gradual worsening since last 1 month. She
reported sensation of food getting stuck in the chest but denied any regurgitation or vomiting. She
denied for chest pain or shortness of breath. Physical examination and initial laboratory data were
unremarkable. Patient had EGD and colonoscopy before 6 months, which were normal. Biopsies from
the esophagus were negative for eosinophilic esophagitis. Her barium esophagogram including 13mm
barium pill swallow was also normal. Patient was further investigated for CAD in the light of negative
work up for any gastrointestinal disorder. Though she had negative exercise nuclear stress test, elective
Left heart catheterization was pursued. It revealed severe CAD reported as “left main equivalent”
disease involving proximal LAD, first Ramus Intermedius ostium and proximal first Obtuse Marginal in
the Left Circumflex system. On echocardiogram, ejection fraction was preserved at 62% with grade 1
diastolic dysfunction. She underwent triple vessels CABG. Surprisingly, her dysphagia symptoms resolved
completely after postoperative recovery.
DISCUSSION: Dysphagia has been reported in the literature as the cause of cardiovascular disease due
to external mechanical compression from the great vessels in form of Dysphagia Aortica and Lusoria.
Valvular heart disease can also cause dysphagia secondary to left atrial enlargement. It has not been
reported as a presenting symptom of CAD. CAD typically presents with chest pain or angina pectoris on
physical exertion that may spread to the left arm or the neck, back, throat, or jaw. Atypical symptoms
include (but not limited to) back, neck, or jaw pain, nausea, vomiting, indigestion, weakness, fatigue,
dizziness, light-headedness. Other Known presentations of CAD include angina with atypical features,
exertional dyspnea alone, myocardial infarction, cardiac failure, arrhythmias, sudden cardiac death or
uncommonly with fatigue, stroke or thromboembolic events. In our case, upper GI workup was normal
for dysphagia, hence cardiac investigations were considered. Left heart catheterization revealed severe
CAD which was then treated with CABG. Post-operatively, her dysphagia symptoms resolved completely.
In conclusion, this case suggests us to consider work up for ischemic heart disease where dysphagia has
unidentified cause of origin. It could be a step to defuse the ticking bomb in time.
518

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Gaurav S Shah
A RARE CASE OF PARADOXICAL RENAL EMBOLUS THROUGH PATENT FORAMEN OVALE
Gaurav S Shah Second authors: Bhavesh B Barad, Parag A Brahmbhatt, Laura Farrington, Koyamangalath
Krishnan
INTRODUCTION: Isolated paradoxical renal embolism has been reported very rarely in literature. We
report a case of paradoxical unilateral renal embolus due to patent foramen ovale (PFO) in an otherwise
healthy Caucasian female.
CASE PRESENTATION: A 42 year old Caucasian female was admitted to the hospital due to severe flank
pain associated with nausea and vomiting for 4 days. Computed Tomography (CT) of abdomen without
contrast done 2 days ago was without any abnormalities. Medical history was significant for
hypothyroidism and migraine. She was taking Armour thyroid, oral contraceptives and topiramate. On
examination she had flank and left lower quadrant abdominal tenderness. Labs showed normal
electrolytes, renal function and benign urinalysis. There was leukocytosis (14.7) without any other
evidence of infection. CT abdomen with contrast was done and showed left renal infarction.
Hypercoagulable work up was ordered while patient was started on heparin and warfarin and later on
warfarin alone after adequate bridging. Subsequently lower extremity venous doppler was done, which
was negative for Deep Venous Thrombosis. Echocardiogram with bubble study was ordered which
showed patent foramen ovale (PFO) with significant right to left shunt. Renal artery angiography was
done which ruled out local causes like fibromuscular dysplasia, aneurysm or dissection. While awaiting
hypercoagulable work up results, closure of PFO was performed. Patient was later discharged on
warfarin with follow up as outpatient in 1 week. On follow-up, patient was asymptomatic with
hypercoagulable workup negative, hence warfarin was discontinued.
DISCUSSION: Paradoxical emboli due to PFO are known to result in cryptogenic stroke, but it’s rarely
reported to cause renal infarction. Cases reported show that patients with PFO have higher incidence of
paradoxical emboli not only due to preformed thrombus, but also in some instances due to certain
thrombogenic chemicals which are thought to get metabolized in lungs. Studies have reported increased
incidence of re-embolization in patients with unrepaired PFO who already have suffered from embolic
event. Repair of PFO in such individuals results in considerable symptomatic improvement as well as
marked reduction in incidence of further paradoxical embolus. We advise clinicians to have high index of
suspicion to consider the diagnosis of renal infarction secondary to paradoxical embolus in a patient
with history of PFO in appropriate setting. Proper diagnosis and timely treatment can significantly
reduce morbidity as well as serious complication like myocardial infarction, stroke, transient ischemic
attack and limb ischemia. Further research about possible thrombogenic chemicals which may be
metabolized in lungs and results in increased incidence of paradoxical emboli formation should be
considered.
519

TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Gaurav S Shah
SECONDARY HYPERPARATHYROIDISM IN METASTATIC PROSTATE CANCER: A NEW SYNDROME?
Gaurav S Shah Second Author: Bhavesh B Barad, Alan N Peiris, Parag A Brahmbhatt
INTRODUCTION: Secondary hyperparathyroidism is well recognized in renal insufficiency and vitamin
deficiency. Rarely, certain malignancies with metastatic involvement of bone such as breast and
prostate cancer can be associated with hypocalcemia. We report a case of elevated parathyroid
hormone (PTH) in the presence of a normal ionized calcium, normal renal function and vitamin D in a
patient with metastatic prostate cancer.
CASE PRESENTATION: A 77 year old Caucasian male was referred to endocrine clinic because of an
elevated PTH level. On presentation he was feeling weak, nauseated and had a 29 lb weight loss over
the last 2-3 months. He also had a history of colon cancer treated with a partial colectomy about 22
years ago, hyperlipidemia and prostate cancer. His only medications were Finasteride and Simvastatin.
His initial diagnosis of prostate adenocarcinoma was in 1995. Various treatment modalities were tried
including brachytherapy, radiation and chemotherapy. No abnormal physical findings were noted.
Recent bone scan was strongly suspicious for interval development of widespread skeletal metastatic
disease, likely related to prostate cancer. His PSA was 386.52(Normal 0-4.0] and alkaline phosphatase
was 274 [Normal 38-126] which were consistent with metastatic prostate cancer. Treatment with
calcium, Vitamin D followed by bisphosphonates resulted in a dramatic improvement in wellbeing, near
normalization of PTH levels (64/71) and a reduction in alkaline phosphatase (236). However, PSA level
increased (429).
DISCUSSION: We believe that secondary hyperparathyroidism in prostate cancer is underestimated
and likely has multiple etiologies including the presence of vitamin D deficiency and perhaps renal
impairment. However, in our patient another etiology could well be the incorporation of calcium into
osteoblastic metastases, resulting in PTH elevation secondary to the fall in ionized calcium. We believe
that failure to recognize this syndrome may lead to hypocalcemia related to hungry bone syndrome. An
elevated PTH value per se has been linked to a variety of adverse health outcomes including enhanced
mortality. Our patient responded very well to treatment with calcium (1500 mg daily) and vitamin D
(4000 iu D3) followed by bisphosphonates. However, the rise in PSA is concerning and the optimal
treatment for this condition including the role of calcium, vitamin D and bisphosphonates among other
agents need additional studies. However, initial treatment with calcium and vitamin D has the benefit of
improving wellbeing and possibly reducing the side-effects of bisphosphonates. Providers managing
patients with prostate cancer should be cognizant of this phenomenon and check PTH values especially
in the presence of metastases either radiologically or in the presence of elevated alkaline phosphatase
values. The use of bisphosphonates should be made after these considerations are weighed.
520

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Michael J McNeal, MD
Gastric Bypass: Lowering more than weight
Michael McNeal MD, Shannon Ward DO, Maybelline Lezama MD
INTRODUCTION: Gastric bypass surgery offers significant weight loss and is a powerful tool to fight
obesity and its related adverse health conditions, but it is not without complications. Many physicians
are aware of the common complications. However, gastric bypass has recently been implicated in
noninsulinoma pancreatogenous hypoglycemia, a rare but significant side effect which can occur even
years after surgery.
CASE PRESENTATION: A 46 year-old white female eight years post gastric bypass surgery presented to
our hospital with recurrent pancreatitis. During her recovery, she began to experience postprandial
hypoglycemia with blood glucose levels in the 20s-30s. Laboratory values were checked during one such
event revealing a glucose of 23, elevated c-peptide, no insulin antibodies, and an insulin level in the
normal range with a negative hypoglycemic agent screen. Imaging did not reveal a pancreatic mass. A
selective arterial calcium stimulation test was consistent with non-insulinoma hyperinsulinemic
hypoglycemia. She was started on a low to no carbohydrate, high protein, and high fat diet with 6 meals
per day with complete resolution of her hypoglycemia.
DISCUSSION: Beta-cell hypertrophy following gastric bypass surgery represents a rare but troubling
complication for those affected. The mechanism for this process has not yet been established, but one
postulated mechanism involves stimulation of beta cell growth from gut hormones that happens over
time. Gastric bypass can cause rapid delivery of stomach contents to the distal ileum resulting in
elevated levels of glucagon-like peptide 1, which has been shown to increase beta cell mass in rodents
and decrease islet cell apoptosis in humans. The true mechanism warrants further study because of the
possibility it holds not only for treatment of these patients but it may represent future targets in
diabetic management.
521

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Linh M Lu, DO
Contagion From Horse to human: Streptococcus Equi Bacteremia in a Horse Lover
Linh Lu, Barbara Atkinson, Saji Pillai, Aldon Li
INTRODUCTION: A 51 year-old Caucasian female with Diabetes Type 1, coronary disease, and splenic
atrophy was hospitalized for chest pain and fevers. Her initial emergency room visit was inconclusive for
a source and dismissed home. The patient continued to have two weeks of intermittent fevers and
returned to the hospital with fatigue, night sweats, nausea and vomiting associated with left substernal
chest pain radiating to her left jaw and arm. She denied acute fever, sick contacts, travel or recent
illness. She reportedly received all childhood and adult immunizations, including influenza,
Pneumococcal, and Haemophilus influenza type b, tetanus and meningococcal vaccines. As a hobby, she
feeds, cleans, and rides horses complicated by multiple scratches on her upper extremities. She denied
recent encounters with sick horses.
CASE PRESENTATION: Physical examination revealed a non-toxic female that was unremarkable other
than a non-radiating 2/6 systolic murmur in the left sternal border and multiple healed excoriations on
both arms. She had a temperature of 102.8 o F on admission. The fevers waxed and waned during
hospitalization with the highest temperatures recorded in the evening hours.
Cardiovascular workup including transthoracic echocardiogram were unremarkable. Diagnostic
laboratory exam was normal except for a leukocytosis of 25.9 k/mm3, bandemia of 9%, C-reactive
protein of 81.6 mg/L and two blood cultures grew Streptococcus equi. Her chest discomfort, fevers,
weakness, and leukocytosis resolved with intravenous penicillin.
DISCUSSION: Streptococcus equi is a Group C Streptococci bacterium that most commonly causes
strangles infection in horses. Equine strangles leads to lymphadenopathy, respiratory distress and
death. It is an unusual zoonotic infection with only a handful of reported cases of equine-to-human
transmission. The patient’s immunocompromised state of splenic atrophy and diabetes mellitus
coupled with handling horses likely contributed to her susceptibility to this bacteremia. She was
counseled to limit contact with horses, avoid consumption of unpasteurized foods, continuation of oral
Penicillin V K for 21 days and discharged home in stable condition. Immunocompromised patients with
animal exposure should be considered for Streptococcus equi bacteremia as humans are rare
hosts. Strangles infected horses are treated in isolation but it is unclear if infected humans require
isolation precautions. Further studies into understanding the transmission of S. equi from equine-tohumans
may give insight into cross species bacterial evolution.
522

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Salman Jamaluddin Bandeali,
MBBS
Doctor, I Can "Not Stop Vomiting!"
Salman Jamaluddin Bandeali, MBBS Second Author: Jolie Britt Third Author: Anna L Kolpakchi, MD Last
author: Dr. Lee Lu Bach, MD
INTRODUCTION: Emesis can manifest as a presenting feature of various systemic diseases. Sometimes,
this nonspecific symptom can be a diagnostic challenge. We present a curious case of persistent nausea
and vomiting.
CASE PRESENTATION: A 47-year-old African American male with a past medical history of poorly
controlled hypertension and ventral hernia presented with intractable nausea and non-bilious, nonbloody
vomiting. He reported early satiety with a 30 pound unintentional weight loss. He denied
dysphagia, odynophagia, fevers, abdominal pain, diarrhea or constipation. He had no sick contacts or
recent travel. The patient’s symptoms started 2 months prior at which time he was admitted with
dehydration and acute kidney injury with a creatinine of 3.4 mg/dL from a normal baseline. Urinalysis
showed granular casts and proteinuria. He was managed conservatively with bowel rest, anti-emetics
and hydration, and his creatinine improved to 2.0 mg/dL but failed to normalize completely. He was
presumed to have developed chronic kidney disease due to long-standing untreated hypertension as
evidenced by medical renal disease on ultrasound. His nausea and vomiting persisted with intermittent
flares requiring multiple emergency room visits. One month later, he was admitted again for the same
complaints. An abdominal CT scan showed an incidental supraumbilical hernia along with a ventral
hernia, but no evidence of incarceration. The ventral hernia was thought to be the source of his
intractable nausea and vomiting; thus, a laparoscopic hernia repair was performed. Few weeks later, his
symptoms recurred. Physical exam at that time was significant for exaggerated bowel sounds and a liver
span of 14cm. Laboratory studies showed a creatinine of 2.9mg/dL and 3(+) proteinuria. Renal
ultrasound reported left and right kidney size to be 13.7 and 12.8cm, respectively. Esophagogram was
normal, and gastric emptying study showed accelerated gastric emptying. An
esophagogastroduodenoscopy (EGD) revealed antral erythema, and the biopsy of duodenal mucosa was
positive for Congo red staining. Serum protein electrophoresis identified IgG kappa and lambda M
spikes. Bone marrow biopsy showed 5% plasma cells. A diagnosis of “AL” amyloidosis with
gastrointestinal involvement was made. The patient received bortezomib and dexamethasone
treatment and had resolution of his symptoms.
DISCUSSION: Nausea and vomiting is one of the most common complaints but at times can implicate
specific diagnostic clues. Gastric and duodenal involvement in “AL” amyloidosis occurs in 8% of patients
by biopsy, with only 1% cases being symptomatic. Patients typically present with nausea, vomiting,
epigastric pain, and bleeding. Weight loss is an independent poor predictor of survival. Treatment
involves the same chemotherapy used in multiple myeloma. Hence, although rare, gastrointestinal
symptoms in a patient with hepatomegaly, proteinuria, and renal dysfunction should raise suspicion for
amyloidosis.
523

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Niru Cepeda-Iruegas, MD
Everything Old is New Again: Weakly positive AFB Cavitary Lesion in an HIV infected patient with
Sepsis.
Niru Cepeda-Iruegas, MD Other Authors: James F. Hanley, MD Laura Garcia, MD
INTRODUCTION: Rhodococcus equi infections have been associated with profound impairment of
cellular mediated immunity, predominantly AIDS with CD4 lymphocyte counts below 200/microL, but
can also be seen in lymphoproliferative malignancies, solid organ transplants, chronic steroid and
immunosuppressive therapy use. R. equi is a pleomorphic gram positive rod. It can be an acid fast
producer and have a micolic acid cell wall. Route of inoculation is typically inhalational (cases of
inoculation by ingestion, post-trauma or wound superinfection have been reported as well) with these
bacteria usually affecting the lung and GI tract of immunocompromised patients.
Before the AIDS epidemic, human related disease was rarely published, however with the increasing
prevalence of AIDS, Rhodococcus equi infections became more common. Nowadays it is well known that
ART and prophylaxis for MAC has contributed to the decline in R. equi cases.
CASE PRESENTATION: 43 year old man with history of smoking presented with a 1 month history of
dry cough, pleuritic chest pain, weight loss, and generalized weakness. Physical exam revealed an
afebrile cachectic male in mild respiratory distress with clubbing and seborrheic dermatitis.
Further testing revealed bilateral infiltrates and blebs on CXR, HIV viral load of 400,000 copies, a CD4 of
26 c/uL, and a negative PCP PCR.
During hospitalization, he was treated for community acquired pneumonia and was discharged with
ART, fluconazole, azithromycin, sulfamethoxazole/trimethoprim and a pending bronchoaveolar lavage
report.
4 months later, the patient presented after not filling the discharge medications with low grade fever,
hypotension, tachypnea, dry cough, and an episode of hemoptysis. During this admission workup
revealed a cavitary lesion in right upper lobe seen on CXR, a CD4 count of 8 c/uL, AFB report positive for
branching rods, and blood cultures positive for Rhodoccocus equi. He was treated with rifabutin and
vancomycin IV for 2 weeks.
DISCUSSION: Rhodoccocus equi infections are uncommon in the general population and have
undergone fluctuating incidence before, during and after the AIDS epidemic. Needless to say AIDS and
other immune-compromised patients have increased risk for this infection.
Infection usually compromises the pulmonary and gastrointestinal system. 50% of the patients infected
with Rhodoccocus equi who present with a cavitary lesion will have bacteremia even in the absence of
systemic inflammatory response syndrome criteria, and consequently blood cultures will be crucial in
the diagnostic approach.
Prognosis in R. equi infected AIDS patients depends on prompt diagnosis and treatment which is difficult
because it may be thought of as a contaminant and a high index of suspicion is fundamental.
524

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Cindy Douglas, MD
Acute abdomen in systemic lupus erythematosus: is surgery warranted?
Cindy Douglas, MD
INTRODUCTION:Lupus peritonitis is a rare entity that may present with signs and symptoms identical
to an acute abdomen. Early diagnosis is important not only for determining management strategies, but
also to avoid unnecessary surgical intervention.
CASE PRESENTATION: A 44 year-old African American female presented to the emergency department
for a one week history of increasing abdominal pain and distension. The pain was described as severe,
constant, and diffuse, and was associated with vomiting, fevers, and chills. Physical exam revealed a
distended abdomen with exquisite tenderness to palpation and involuntary guarding. CT scan showed
only trace free fluid in the abdomen with areas of nonspecific small bowel wall thickening. The patient’s
past medical history was significant for SLE, managed with chronic Cellcept and low dose prednisone
therapy, and her disease had been well-controlled, with her last flare occurring several years prior to her
current admission. Because of her chronically immunosuppressed state and concern for spontaneous
bacterial peritonitis, a paracentesis was performed; prelimary studies showed the fluid to be exudative
but non-inflammatory, with RBC count 280, WBC 370 (total granulocyte count 52). She was started on
broad-spectrum antibiotics pending further results of the fluid studies. General surgery was called in
anticipation for emergent laparotomy, as the patient continued to have severe abdominal pain and
increasing distension despite antibiotic therapy, intravenous fluids, and pain medication. Shortly before
being taken for surgery for a suspected acute abdomen of unclear etiology, the patient was seen by
Rheumatology, who recommended high-dose intravenous corticosteroids for possible lupus
serositis. The patient showed an immediate response, with marked improvement in both her abdominal
pain and distension. Surgery was avoided, and the patient’s symptoms resolved over the next several
days on continued steroid therapy. Ascitic fluid gram stain and cultures were eventually found to be
negative; at that time, serum complement levels were also noted to be markedly decreased. The final
diagnosis was lupus peritonitis presenting as an acute abdomen.
DISCUSSION: Peritonitis as a manifestation of active lupus is relatively rare and is usually associated
with other symptoms of an acute lupus flare; rarely does it occur in the absence of other signs of disease
activity. Symptoms of lupus peritionitis closely mimic those of an acute abdomen, which may lead to a
mistaken diagnosis and, in some instances, unnecessary surgery. Patients with lupus peritonitis do not
require surgery and respond dramatically to pulse steroids, often recovering from the episode without
sequelae. In patients with systemic lupus erythematosus who present with acute abdominal pain, the
diagnosis of lupus peritonitis must be considered in order to facilitate early diagnosis and prompt
therapeutic management, as well as preventing unnecessary surgical procedures.
525

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Jennifer Lynne Jarvie
Acute Liver Failure in Pregnancy - Not Always HELLP
Jennifer Lynne Jarvie Second Author: Stephen Harder
INTRODUCTION: CASE PRESENTATION: A 26 year-old G4P3 Caucasian female in her 27 th week of
pregnancy presented with right sided abdominal and flank pain for one week. She had taken ibuprofen
and acetaminophen for the pain at recommended doses with some relief. On the initial physical exam
she had a low-grade fever and right upper quadrant tenderness. The laboratory analysis was significant
for a mild transaminitis with ALT 164 U/L and AST 179 U/L. Alkaline phosphatase (AP) and total bilirubin
were within normal limits, as were the hematocrit and platelets.
The patient was admitted and over the next five days she experienced a rapid clinical decline
characterized by hypotension, tachycardia and somnolence with intermittent fevers. Physical
examination was remarkable for an altered sensorium, asterixis, increased right upper quadrant
tenderness and a palpable liver edge. Repeat laboratory testing was concerning for an AST >4000 U/L,
ALT 2265 U/L, AP 280 IU/L, and total bilirubin 2.7 mg/dL. She became acutely anemic (hematocrit 22.0
mg/dL), thrombocytopenic (platelets 22 x 10(3) uL) and coagulopathic (INR 1.85). No schistocytes were
seen on smear. She was emergently delivered by cesarean section for concern of HELLP (Hemolysis,
Elevated Liver Enzymes and Low Platelets) syndrome or acute fatty liver of pregnancy.
Post-partum she was transferred to the intensive care unit. Despite delivery her liver injury
progressed. A secondary liver workup revealed ceruloplasmin 16.5 mg/dL (reference range 16.0 – 45.0)
and a ferritin over 41,000 ng/mL (reference range 13.0 – 150.0 ng/mL). The serum acetaminophen level
was

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Myung Sun Kim, MD
Discerning the origin of bone marrow blast cells, a 59 year old Caucasian male with pancytopenia
Myung Sun Kim, MD Co Author: Jose A. Perez MD
INTRODUCTION: Multiple myeloma is a clonal B-cell neoplasm that affects plasma cells. The diagnosis
is made by establishing the presence of M protein in serum or urine, and confirming the presence of
more than 10% clonal plasma cells in the bone marrow. The following case is a rare presentation of
multiple myeloma with myelofibrosis, pancytopenia, anaplastic plasma cell morphology, and absence of
serum paraprotein.
CASE PRESENTATION: A 59 year old Caucasian male was referred to hematology clinic for
pancytopenia. He was morbidly obese and had a 1 month history of progressively worsening right sided
back pain aggravated by movement which severely limited his activities. On examination, he appeared
comfortable. Musculoskeletal exam showed point tenderness of the right posterior 5 th rib. Abdomen
was soft and globoid, with tenderness in both upper quadrants. Splenomegaly was not appreciated.
Complete blood count was remarkable for white count of 3.27K/µL, hemoglobin of 8.3g/dL, hematocrit
of 25.9% and platelet count of 78K/µL. Renal function was normal with BUN of 21mg/dL and creatinine
of 1.1mg/dL. Calcium level was 9.5mg/dL with serum protein and albumin 6.0g/dL and 3.9g/dL
respectively. Peripheral blood smear showed 7% immature neutrophils, 1 nucleated RBC and 1 tear drop
cell per high powered field, suggesting myelofibrosis. Bone marrow biopsy demonstrated tumor clumps
with more than 50% blast-like cells exhibiting prominent cytoplasmic projections. These cells resembled
budding platelets and were suggestive of acute leukemia. A diagnosis of acute megakaryoblastic
leukemia (M7) commonly presenting with acute myelofibrosis and pancytopenia was made. The patient
was admitted for chemotherapy. Further studies surprisingly revealed that the tumor cells were positive
for CD138, MUM-1 and kappa light chain on immunohistochemical staining, confirming a diagnosis of
multiple myeloma. Serum protein electrophoresis did not show a M spike, however Kappa/Lambda ratio
was markedly elevated to 643. Beta-2 microglobulin was elevated to 5.4mg/L. The patient began
treatment with bortezomib, dexamethasone and doxorubicin and is being worked up for stem cell
transplant.
DISCUSSION: This is a rare case of nonsecretory multiple myeloma with highly undifferentiated
cytomorphology. The initial presentation with myelofibrosis and pancytopenia in the absence of
monoclonal gammopathy led to a misdiagnosis of acute myeloid leukemia. Nonsecretory myeloma
represents less than 5% of all cases of multiple myeloma and the absence of monoclonal gammopathy,
may delay the diagnosis. This case illustrates that multiple myeloma still remains a possible cause of
bone marrow infiltration in the absence of serologic evidence of a paraprotein and that the use of tumor
specific markers on immunohistochemical staining is important in avoiding the misdiagnosis and
mistreatment of hematologic malignancies.
527

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Manuel Lopez Vazquez, MD
LEVAMISOLE: COCAINE'S DEADLY SECRET
Manuel Lopez Vazquez, MD (Associate) Natraj Shanmugam, MD (Associate) James Hanley, MD (FACP)
Nabeel Sarhill, MD
INTRODUCTION: Cocaine can be hazardous not only for its cardiovascular effects but also due to
lesser-known toxicities from drug-diluting agents. We present a case of a patient who ingested cocaine
and survived both a coronary event and agranulocytosis, most likely related to the cutting agent
levamisole.
CASE PRESENTATION: A 38-year-old Mexican man presented with one day of sudden onset left shin
pain, with generalized weakness and dyspnea. His temperature was 99.0, blood pressure 108/72, pulse
90, respiratory rate 24. On exam he had erythema of the left shin, calf tenderness and decreased range
of motion. EKG showed right bundle branch block without ST elevation. Dopplers of the lower
extremities were negative. He had a WBC count of 300 with an absolute neutrophil count of 0.
Peripheral smear showed no blast forms. Bone marrow showed no evidence of leukemia. Flow
cytometry did not reveal any immunophenotypic evidence of a myeloid stem cell disorder or non-
Hodgkin’s lymphoma. CK rose above 8,000 and troponin I peaked at 2.3. Urine toxicology was positive
for cocaine and cannabinoids. HIV screen was negative. He was medically managed, and placed on
broad spectrum antibiotics and filgastrim. Although he initially denied cocaine usage, upon further
questioning the patient admitted to having snorted cocaine powder on a daily basis and obtaining the
drug from a dealer in Mexico who had been mixing the cocaine with an unknown substance. At this
point, the etiology of his neutropenia was highly suspected to be levamisole-contaminated
cocaine. Unfortunately, initial urine samples were unavailable for levamisole testing at the time the
diagnosis was being contemplated. His WBC count eventually recovered within five days and the skin
lesion resolved.
DISCUSSION: Ultimately, the patient survived both common (myocardial infarction) and uncommon
(agranulocytosis) complications of cocaine abuse. Levamisole is a veterinary antihelminthic drug once
used in humans as adjuvant therapy for colon cancer. Eighty-two percent of seized cocaine in the U.S. is
adulterated with levamisole. Dealers prefer levamisole over traditional cutting agents such as baking
soda because it potentiates cocaine's euphoric effects. However, in select patients (2.3%) it causes
agranulocytosis via immune-mediated destruction of cell membranes by antineutrophil antibodies,
predisposing patients to serious infections. It may also produce an ANCA-related cutaneous vasculitis.
Clinicians need to be cognizant of these rare but life-threatening complications when managing patients
who use cocaine.
528

TEXAS POSTER FINALIST - CLINICAL VIGNETTE Kamil Muhyieddeen, MD
Single Coronary artery with apical ischemia
Kamil Muhyieddeen, MD
INTRODUCTION: Single coronary artery is an extremely rare congenital anomaly. Most isolated single
coronary artery anomalies are benign. However, 15% of isolated single coronary artery may have
myocardial ischemia directly caused by the abnormal anatomy of the arteries and not by coronary artery
disease. Herein, we report a case of single coronary artery causing apical ischemia, with the absence of
coronary artery disease.
CASE PRESENTATION: A 56 year-old female presented with chest pain. She had no risk factors for
coronary artery disease. Physical exam was normal. Her cardiac enzymes were negative. EKG showed
normal sinus rhythm. Chest X- ray was normal.
Stress exercise echocardiogram showed left ventricular apical ischemia. Coronary angiogram showed no
significant lesions in a large dominant right coronary artery, but the left coronary artery could not be
found. CT coronary angiography for further evaluation of the coronary artery anatomy was done. It
showed a single coronary artery arising from the right coronary sinus. It coursed around the entire
atrioventricular groove, giving off all main coronary branches, and then directed anteriorly, ending in the
mid anterior interventricular groove. Patient was managed medically.
DISCUSSION: Coronary artery anomalies are found in about 1.3% of patients undergoing coronary
angiography. However, Single coronary artery is an extremely rare congenital anomaly characterized by
a single coronary artery ostium from an aortic sinus, which is seen in only 0.024% to 0.066% of patients
who undergo coronary angiography. Most anomalies are encountered as incidental findings during
coronary angiography or at autopsy. About 80% of coronary artery anomalies are benign while 20%
produce life threatening symptoms including arrhythmias, syncope, myocardial infarction, or sudden
death. 15% of isolated single coronary artery may have myocardial ischemia directly caused by the
abnormal anatomy of the arteries and not by coronary artery disease. CT coronary angiography is a
noninvasive method that provides detailed 3-dimensional (3D) visualization of complex coronary artery
anatomy, and has currently become the method of choice for the detection and classification of
coronary artery anomalies.
529

TEXAS POSTER FINALIST - CLINICAL VIGNETTE CPT Stephen J Park, MC USAF
A Case Of Refractory Autoimmune Hepatitis Treated With Rituximab
CPT Stephen J Park, MC USAF
INTRODUCTION: Autoimmune hepatitis (AIH) is a chronic hepatitis of unknown etiology that is
characterized by circulating autoantibodies, hypergammaglobulinemia, and necroinflammatory changes
on liver histology. The disease is rare, with a mean incidence of 1-2 per 100,000, and is more frequent in
females. Most cases respond to the standard therapy of corticosteroids and azathioprine.
CASE PRESENTATION: A 23 year old previously healthy male presented with several months of
fatigue. He otherwise denied fever, jaundice, pruritis, ascites, or abdominal pain. He had no history of
alcohol or illicit drug use, and was not taking any medications. He was afebrile with stable vital
signs. Physical exam showed splenomegaly but no other abnormalities. Lab values revealed a WBC
count: 2,700; platelet count 96,000; AST: 338 U/L; ALT: 264 U/L; total bilirubin: 2.5 mg/dL (direct
bilirubin: 1.5 mg/dL); alkaline phosphatase: 125 IU/L; albumin 3.3 g/dL; INR: 1.4. Further workup
showed positive antinuclear, anti-smooth muscle, anti-actin, and perinuclear antineutrophil cytoplasmic
antibodies, and an elevated immunoglobulin G level of 2606 mg/dL. MRI of the liver demonstrated
cirrhosis, splenomegaly, and a 1.2 cm right hepatic lobe lesion, which upon further evaluation with a
three phase liver CT, excluded hepatocellular carcinoma. A percutaneous liver biopsy revealed severe
interface hepatitis with a lymphoplasmacytic infiltrate and cirrhosis. Autoimmune hepatitis was
diagnosed, and treatment was started with prednisone 40 mg daily. After one month, the patient’s
fatigue had not improved and his AST, ALT, and bilirubin had increased to 616 U/L, 522 U/L, and 3.8
mg/dL, respectively. Mycophenolate mofetil was then added. However, after 7 months of this regimen,
his AST, ALT, and bilirubin remained elevated at 438 U/L, 302 U/L, and 3.1 mg/dL, respectively. He was
then treated with two infusions of rituximab, and two months later his AST, ALT, and bilirubin have
decreased to 124 U/L, 87 U/L, and 2.2 mg/dL, respectively, with improvement in his fatigue.
DISCUSSION: The standard treatment for AIH is prednisone or lower dose prednisone in combination
with azathioprine; our patient failed prednisone and azathioprine was relatively contraindicated due to
his leukopenia and thrombocytopenia. Mycophenolate mofetil, widely considered the most promising
alternative agent, was also ineffective. Initial treatment with rituximab, a monoclonal antibody directed
against B-lymphocytes, has been effective thus far. Rituximab, while approved for chronic lymphocytic
leukemia, Non-Hodgkin’s lymphoma, and rheumatoid arthritis, has been shown to have some benefit in
AIH, however this is limited to isolated case reports and a six patient phase 1 study. It may prove to be
an option in the future for AIH treatment failures or for patients who are poor candidates for steroids
and azathioprine, but further investigation is necessary.
530

USAF POSTER FINALIST - CLINICAL VIGNETTE CPT Frederic A Rawlins, III DO
PULMONARY LANGERHANS CELL HISTIOCYTOSIS MIMICKING UNCONTROLLED ASTHMA
Frederic A Rawlins III Capt, USAF, MC (associate), James E Hull Capt, USAF, MC(associate), Julia A
Morgan D.O. SAUSHEC Internal Medicine, San Antonio, TX
INTRODUCTION: INTRODUCTION: Pulmonary langerhans cell histiocytosis (PLCH) is an upper lobe
predominant cystic lung disease that is cause by abnormal proliferation and dissemination of histiocytes
within the pulmonary parenchyma. PLCH is typically seen in young adults who abuse tobacco and is
most prevalent in the third or fourth decade of life without gender predominance. There is a tendency
for females to present at a later age than males. Typical symptoms on presentation include dyspnea,
cough or chest pain. Occasional patients present with constitutional symptoms or hemoptysis. Rarely
patients present with a pneumothorax or symptoms of pulmonary hypertension. There have been few
case reports in English literature of PLCH developing in asthmatics, none of which mimic symptoms of
uncontrolled asthma. We report a patient who presented with uncontrolled asthma (dyspnea,
wheezing, coughing and chest tightness) that was refractory to typical asthma therapy and was found to
have PLCH upon further evaluation.
CASE PRESENTATION: Case: A 26 year old female with active tobacco abuse, who was diagnosed with
asthma based on symptoms and a positive methacholine challenge test (PC20 < 8) who presented with
progressively worsening symptoms of dyspnea, wheezing, coughing and chest tightness. Her symptoms
continued to progress despite appropriate inhaled therapy (inhaled corticosteroids/long acting betaagonists,
anticholinergics), singulair, antihistamines and a proton pump inhibitor. Her pulmonary
function testing, IgE level, ANCA levels and chest x-ray were unrevealing of the underlying etiology. High
resolution CT (HRCT) scan of the chest revealed multiple upper lobe predominant thin walled cysts with
scattered 3 mm nodules along the interlobular septa. Bronchoscopy with transbronchial biopsies
revealed interstitial CD1a, S100 positive histiocytes confirming the diagnosis of PLCH.
DISCUSSION: DISCUSSION: When typical therapy for asthma fails to control symptoms, further
investigation into possible potentiating or alternative etiologies should be performed. There are few
cases reported in English literature of PLCH associated with asthma. Our patient illustrates the
diagnostic complexity of this rare disorder for which there is often a delay in diagnosis of up to several
years due to the variability of symptoms and their severity on clinical presentation. HRCT scan of the
chest typically reveals a combination of upper lobe predominant nodules and cysts. The diagnosis is
confirmed with CD1a, S100 positive histiocytes on biopsy (bronchoscopy or surgical) with special stains.
Birbeck granules on electron microscopy are pathognomonic, but not necessary for diagnosis. Cigarette
smoking is either a cause or could potentiate PLCH, therefore tobacco cessation is the first line of
therapy. Rarely, patients do not respond to tobacco cessation alone and may require
immunosuppressive therapy.
531

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Charlene A Vestermark
Gibb, DO
DRUG INDUCED LUPUS ERYTHEMATOSUS IN A PATIENT WITH ULCERATIVE COLITIS TREATED WITH
INFLIXIMAB PRESENTING AS RECURRENT PLEURAL EFFUSION
CPT Charlene A Vestermark Gibb, DO, MAJ Michael Hjelkrem, MD (Member), LTC John Godino, MD,
MAJ Karen Sky, MD (Member)
INTRODUCTION: Throughout the years, multiple drugs have been reported to cause drug induced
lupus erythematosus (DILE). With the increasing use of TNF-a inhibitors in inflammatory bowel disease
(IBD) and rheumatologic diseases there are increasing reports of DILE in these medications.
CASE PRESENTATION: Our case involves a 40 yo female with a long history of ulcerative colitis (UC)
and IBD related arthritis treated with high dose infliximab every 6 weeks for 5 years. After 5 years of
treatment she began having increasing shortness of breath with multiple hospitalizations for recurrent
left sided pleural effusions after a bout of pneumonia. The pleural fluid was exudative without evidence
of infection and transbronchial biopsy showed no evidence of inflammation, infection, intraalveolar
exudates, or malignancy. While initially unilateral, the pleural effusions eventually occurred on the right
side as well, thus suggesting a cause other than pneumonia.
Serum anti-nuclear antibody (ANA) was positive 1:5120 and ANA in the pleural fluid was positive to
1:5120, as well. Additional labs revealed positive double stranded DNA (dsDNA) antibiody, negative
Smith antibody, negative SSA and SSB antibodies and negative anti-histone antibodies. The pleural
effusions completely resolved after stopping the infliximab and switching therapy to adalimumab.
DISCUSSION: This is a case of bilateral, episodic pleural effusions most likely attibutible to infliximab
based on resolution of symptoms after stopping the medication, a high titer positive ANA and positive
dsDNA. With increasing use of anti-TNFa medications for autoimmune disorders more atypical cases of
DILE are appearing. Anti-TNF related DILE typically presents with rash, arthralgia and fever and while
reported, most of the cases of pleural effusions due to TNF inhibitors have occurred on rheumatic
diseases and are discussed in rheumatology literature. Infliximab has been used in Crohn’s disease since
1998 and has more recently (2005) been approved for use in UC. This is the first reported case of a UC
patient with infliximab related DILE manifesting as recurrent pleural effusions. This is important for
internal medicine physicians to understand as recognition of this potential side effect is vital as
symptom resolution requires discontinuation of the offending agent.
532

UTAH POSTER FINALIST - CLINICAL VIGNETTE Sonja Raaum, MD
Neurocysticercosis or Neuro-metastatic Merkel Cell Carcinoma?
Sonja Raaum MD Srinivas Tantravahi MBBS MRCP Theresa L. Werner MD
INTRODUCTION: Merkel cell carcinoma is a rare non-melanoma skin cancer, with incidence rate in the
general population of less than 0.5 per 100,000 person years. It is associated with increased age and
history of extensive sun exposure, as well as a Polyomavirus identified in 2008. Recent literature
suggests the incidence of Merkel cell carcinoma is increasing, and recognizing the manifestations of its
disease will become more important in an aging population.
CASE PRESENTATION: Patient was a 76 year old male with history of CAD, HTN, hyperlipidemia, BPH,
rheumatoid arthritis, and stage IV Merkel Cell Carcinoma (MCC) of left parotid and left forehead, treated
with chemotherapy with excellent response, who presented in August 2011 with abrupt onset of
confusion, aphasia, dysmetria, and inability to perform simple tasks. After presentation to outside ED,
he had a generalized tonic-clonic seizure. Initial work-up with head CT revealed multiple hypodense
lesions in right cortex. After stabilization, he was empirically started on Albendazole for presumed
neurocystercisosis and transferred to University of Utah Neurology service.
Prior to this presentation, patient had 2-3 week gradual onset of confusion after a syncopal episode.
Regarding his oncology history, patient initially presented with a rapid growing lesion on left side of
forehead as well as an enlarged left parotid gland in February 2011. Biopsy revealed proliferative small
to medium size cells that were negative for chromogranin, strongly positive for CK7 and CK20, and
positive for synaptophysin; consistent with poorly differentiated neuroendocrine tumor or MCC. Staging
PET CT demonstrated widespread osseous disease and a single metastatic lesion in the right hepatic
lobe. He was treated with 4 cycles of Cisplatin and Etoposide and monthly Zoledronic Acid. He received
G-CSF after each cycle to prevent neutropenia. Restaging PET CT on 06/30/11 showed no evidence of
disease other than diffuse uptake in bone, which was thought to be secondary to marrow stimulation
from G-CSF.
Initial differential diagnosis included neurocysticercosis, toxoplasmosis, and neuro-metastatic MCC.
Work-up included lumbar puncture and CSF revealed mild elevation in protein and WBC count.
Infectious work-up including VDRL, Toxoplasma IgG and IgM, as well as cystercercosis antibody IgG was
negative. MRI of brain revealed multiple ring-enhancing lesions throughout the cerebellum and cortex.
Patient was empirically treated with Albendazole during work-up, and did not exhibit any improvement
in mental status. Oncology service was consulted given patient’s prior cancer history; given negative
work-up as well as the findings on brain MRI the most likely diagnosis was neuro-metastatic MCC. Whole
brain radiation was offered, but given diagnosis the patient and his family elected to not pursue further
treatment.
DISCUSSION: While the patient had radiological findings suggestive of neurocystersicosis, this case
does not meet criteria for diagnosis. Patient did not have detectable serum antibodies to Cysterceri and
no resolution or improvement after Albendazole treatment. In addition, he had no risk factors for
exposure. Other infectious work-up was negative, making the most likely diagnosis neuro-metastatic
MCC.
533

One month prior to diagnosis of neuro-metastatic disease, patient‘s scan showed no evidence of disease
and he was asymptomatic. This was a very aggressive recurrence of disease as the median time to
recurrence for MCC is 8 months. Neuro-metastatic disease is rare, and there are only 36 cases reported
in literature.
534

USAF POSTER FINALIST - CLINICAL VIGNETTE Adam L Ackerman, MD
Chronic total occlusion of the proximal right coronary artery successfully treated via a retrograde
percutaneous approach
Capt Adam L. Ackerman, MD, USAF, MC LtCol Steve Kindsvater, MD, FSCAI, USAF, MC
INTRODUCTION: Chronic total occlusion of the coronary artery (CTO) is defined as a >99% stenosis
present for at least 3 months. One-third to one-half of patients with significant coronary artery disease
have at least one CTO, but CTOs account for only 10-15% of percutaneous coronary interventions (PCI).
Successful percutaneous revascularization of CTOs is shown to confer a significant survival benefit over
failed revascularization, with higher rates of avoidance of CABG, and is associated with improvements in
systolic function, angina burden, and exercise capacity. Procedural success (approximately 75%) is
improving without a concomitant increase in complications. Antegrade approaches to proximal lesions
can be complicated by a limited length of vessel to offer support to the interventional wire. A retrograde
approach via septal collateral channels has been shown to be effective and safe in limited studies.
CASE PRESENTATION: Case #1: A 76-year-old male was referred for chronic dyspnea and lack of
exercise tolerance. Transthoracic echocardiogram showed a left ventricular ejection fraction (LVEF) of
25-30% with global hypokinesis. Coronary angiography revealed high-grade atherosclerosis including a
chronic total occlusion (CTO) of the proximal right coronary artery (RCA); distal flow was dependent
upon contralateral collaterals. An initial antegrade approach to the RCA lesion proved unsuccessful; the
lesion was then treated using a retrograde approach. A wire was passed antegrade down the left
anterior descending (LAD), through the septal arcade, and retrograde up the RCA, where the lesion was
successfully crossed. PCI was then performed via an antegrade approach. Five months after the
procedure, the patient’s symptoms remained markedly improved.
Case #2: A 69-year-old male with a history of an enlarging renal mass was referred after a pre-operative
myocardial perfusion study showed reversible inferior wall ischemia. Angiography revealed a CTO of the
proximal RCA with septal collateralization. An initial antegrade approach to the RCA lesion proved
unsuccessful. The lesion was then crossed in a retrograde fashion (see Case #1). At this point, the wire
was further advanced through a guiding catheter in the ostium of the RCA, creating a loop through the
heart with both ends exiting at either groin access site. Successful PCI was then performed in an
antegrade fashion. The patient received bare metal stents to facilitate semi-urgent nephrectomy.
DISCUSSION: Chronic total occlusion of the coronary artery (CTO) is a common finding in patients with
significant coronary artery disease. Successful revascularization of CTOs may confer decreased mortality
and symptomatic benefit to patients. Retrograde percutaneous techniques may be useful in proximal or
ostial CTOs, but are dependent upon the presence of adequate collateral channels for procedural
success.
535

USAF POSTER FINALIST - CLINICAL VIGNETTE Sabrina M Sumner, DO
Dexmedetomidine In The Treatment Of Acute Alcohol Withdrawal Cpt Sabrina Sumner, DO
(Associate), Ltcol Matthew Carroll, MD (Fellow) Keesler Medical Center, Biloxi, MS
Sabrina M Sumner, DO
INTRODUCTION: Complications of alcohol withdrawal are a common scenario every physician will
encounter. First line efforts to manage withdrawal symptoms are with benzodiazepines, as these agents
enhance GABA activity and prevent neuronal excitability and progression to delirium tremens. However,
some cases require the addition of other agents to achieve appropriate levels of sedation, including
antipsychotics, anticonvulsants, or beta-blockers. Here we present a case where the adjunctive use of
the sedative dexmedetomidine, a sympatholytic with alpha-2 (a2) receptor agonist activity, achieved
sedation in a patient with acute alcohol withdrawal when other first-line agents failed.
CASE PRESENTATION: The role for a2-agonists in the treatment of acute alcohol withdrawal has been
studied in the past with clonidine. Several case reports exist using dexmedetomidine in this role, as it is
ten times more selective for the a2-receptor. Whereas benzodiazepines target the GABA receptor, a2agonists
target the noradrenergic system, providing a different pathway to achieve effect. The side
effect profile is comparable to alternative agents such as barbituates, benzodiazepines, and
antipsychotics. Lastly, dexmedetomidine has been used successfully in combination with other agents
without additive toxicity. This is a novel approach to a very common and serious medical condition that
all physicians face. Currently, no prospective data exists for its use in the management of acute alcohol
withdrawal.
536

US ARMY POSTER FINALIST - CLINICAL VIGNETTE Meredith A Hays, DO
Taking A Bath: A Patient With Persistent Delirium
Meredith A Hays, CPT, DO Second Author: David A. Dorsey, LTC, MD
INTRODUCTION: The use of designer drugs that are not detectable in routine drug screens is becoming
increasingly more common at Fort Bliss, TX. Soldiers are presenting with unexplained, atypical delirium
that eventually clears over 24-72 hours. No etiology of can be found despite comprehensive medical
evaluation including negative serum and urine drug screens. This report reviews one such case that was
caused by intoxication with a legal designer drug methylenedioxypyrovalerone (MDPV), also known as
“Bath Salts”.
CASE PRESENTATION: A 26 year old male with a past medical history of PTSD and polysubstance abuse
presented to WBAMC ER with delirium and hallucinations. The soldier had been reported missing by his
unit and had been located by the military police earlier in the day. He was found in the corner of a
shipping container in his underwear, mumbling to himself and curled up in the fetal position. Upon
awakening, he became combative and attempted to flee. In the ER he was disheveled, volume depleted
and tachycardic with fixed pinpoint pupils. He would answer questions appropriately as long as he was
not touched. However, tactile stimulation caused markedly increased agitation. The soldier was
admitted to the ICU for altered mental status. No etiology was identified despite comprehensive
medical evaluation to include toxin screens, CT scan, lumbar puncture, and MRI. Over the course of five
days in the ICU his mental status slowly improved. During one lucid interval he admitted to taking Rave-
Ice, although he was unsure of what he actually ingested. On the sixth day of admission he had
completely recovered and denied all use of drugs or alcohol. He was transferred to inpatient Psychology
for evaluation and treatment. Some weeks later a specialty lab report returned positive for 3,4methylenedioxypyrovalerone
(MDPV) or mephedrone in the urine.
DISCUSSION: Designer drugs such as mephedrone are becoming an increasingly popular drug of abuse
in the military. Under federal law these agents are sold legally in many states and are readily available
on online and in some stores. Not only are these agents legal but they are undetectable in the standard
drug assays. MDPV is often sold as “Bath Salts”, “Rave Ice”, or “Plant Food.” Like many of these newer
agents MDPV intoxication does not present with a classic toxidrome that clinicians can readily
identify. MDPV presents with multiple clinical features to include sympathomimetic effects,
hallucinations, epistaxis and even death. The effects of these drugs often persist for greater than 48
hours after ingestion as was the case with our patient. Army Medical Officers should have a high index
of suspicion for designer drug intoxication when treating soldiers with unexplained delirium.
537

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Amy N Stratton, DO
Chapter Winning Abstract Subacute Staphlococcus epidermidis bacterial endocarditis complicated by
mitral-aortic intervalvular fibrosa pseudoaneurysm
CPT Amy N Stratton, DO (associate) Tomas Ferguson, MD (FACP, FIDSA) Jone Flanders, DO (FACP, FACC)
INTRODUCTION: The mitral-aortic intervalvular fibrosa (MAIF) connects the anterior mitral leaflet to
the posterior aortic root. The intervalvular fibrosa is an avascular fibrous body which is susceptible to
injury/damage secondary to aortic valve replacement or bacterial endocarditis. Injury can result in
intervalvular fibrosa pseudoaneurysm.
CASE PRESENTATION: The patient is a 75 year old man who underwent aortic valve replacement
(AVR) with a bioprosthetic valve secondary to aortic insufficiency. On histologic examination of the
aortic valve he was found to have endocarditis. Culture of the Aortic as well as Mitral valves were
matching strains of Staphlococcus epidermidis. He was subsequently treated with cefazolin (renally
dosed for GFR

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Aaron Walter
Pumerantz, DO
EOSINOPHILIC FASCIITIS: THE GROOVE SIGN IN A YOUNG MILITARY SOLDIER
Aaron Pumerantz, DO (Associate) Nicholas Kortan, DO (Associate) Jess Edison, MD (Member)
INTRODUCTION:Eosinophlic fasciitis (EF) is an extremely rare connective tissue disease with
approximately 250 new cases per year, characterized by scleroderma-like cutaneous skin changes,
hypergammaglobulinemia, and peripheral eosinophilia. It is crucial to distinguish the differences
between systemic sclerosis (SSc) and EF. Although etiology remains unknown, prognosis is good as
most patients are steroid responsive. We present a case of a young active duty male with EF.
CASE PRESENTATION: A 27 year-old active duty white male presented with progressively worsening 5
month history of bilateral legs then arms swelling, pain, and eventually skin hardening. He additionally
noted myalgias, fevers, fatigue, and night sweats. No clear toxin exposure or new medications. Physical
exam was notable for skin induration in bilateral forearms, and bilateral lower extremities from ankles
to knees, with positive groove sign. The complete blood count was normal except for eosinophlia up to
28%, and his inflammatory markers were elevated. The rest of his laboratory studies were
unremarkable except for elevated immunoglobulin IgG. Left forearm skin and deep tissue biopsy
revealed panniculitis, underlying fasciitis with lymphocytes, plasma cells, and eosinophils, most
consistent with EF. There was no evidence of end organ damage. The diagnosis of EF was made based
upon clinical presentation and biopsy. He was treated with oral corticosteroids 1mg/kg daily, with a
slow taper, and experienced significant improvement.
DISCUSSION: Our case is a common presentation of a rare connective tissue disease, with a classic
physical exam finding. Physically active individuals and those enduring strenuous activities, especially
athletes or active duty military soldiers are at increased risk of EF, a well documented precursor to the
onset of this disease. It is important to understand the differential diagnosis as well as complications of
skin induration and hardening, as the management and prognosis differs significantly. Prognosis for EF
is very good, primarily treated with high dose corticosteroids. With the presence of appropriate risk
factors, clinicians should consider EF in the setting of scleroderma-like cutaneous skin changes.
539

US ARMY POSTER FINALIST - CLINICAL VIGNETTE Brian Joseph Stout, MD
Case Report: Visceral Leishmaniasis (Kala-Azar) in a 34 year old Active Duty Soldier
Brian Joseph Stout, MD, Associate Second Author: Gunther Hsue, MD, FACP
INTRODUCTION: Visceral Leishmaniasis (Kala-Azar; Black Fever) is a potentially lethal disseminated L.
Donovani infection characterized by malaise, fever, weight loss, and splenomegaly. In advanced disease,
patients may exhibit severe anemia, thrombocytopenia and hepatic dysfunction. This systemic disease,
which is much rarer than its cutaneous counterpart, results from transmission of the protozoan parasite
through the bite of the female sandfly. The authors present a case of an active duty soldier who
presented in theater with symptoms of severe nausea and vomiting, extreme lethargy, and rapid weight
loss. This service member was ultimately diagnosed with visceral leishmaniasis, underwent treatment
with amphotericin B, and exhibited rapid clinical improvement.
CASE PRESENTATION: While stationed in Iraq, a 34 year old male presented with symptoms of severe
nausea, vomiting, extreme lethargy, and rapid weight loss of 30 pounds in 2 months. He reported
multiple sandfly bites occuring prior to onset of symptoms. His review of systems and examination were
negative, to include no skin findings. A rK39 assay was performed at the patient’s duty station and
returned highly positive. CT scan of the abdomen at that time showed mild enlargement of the
spleen. The patient was ultimately seen in Infectious Disease clinic at Tripler Army Medical Center and it
was recommended that he undergo definitive treatment for visceral leishmaniasis. Curative therapy was
pursued with Ambisome. The patient received the standard seven infusions of liposomal amphotericin
B, tolerating the therapy well, with only minimal and transient worsening of renal function. Patient
exhibited rapid and complete resolution of symptoms.
DISCUSSION: After infection with L. Donovani, there is a variable incubation period of 2-6 months,
followed by parasitic replication within host macrophages in the reticuloendothelial system (spleen,
liver, and bone marrow. Definitive diagnosis of visceral leishmaniasis requires demonstration of the
parasite by histopathology or culture following needle aspiration or biopsy from the bone marrow or
spleen. Histopathologic diagnosis requires visualization of amastigotes. Diagnosis by culture requires
successful growth of the organism in Novy-McNeal-Nicolle or other parasitic growth media. A more
recent development in the diagnosis of the disease is the rK39 assay test. rK39 is a 39-amino acid repeat
of L. donovani kinesin, a recombinant product used as antigen in ELISA assays and also in rapid strip
tests. Sensitivity for disseminated disease in clinically suspected cases is 81% and Specificity is 97%
(PPV 98%; NPV 71%). In parasitologically confirmed cases, rK39 testing demonstrates 90% sensitivity
and 99% specificity. Treatment regimens for Kala-Azar include Amphotericin B, Pentavalent antimonial
drugs, Paromomycin (a parenteral aminoglycoside), and Miltefosine. Among these therapeutic
modalities, liposomal amphotericin B (Ambisome) is the drug with the highest therapeutic efficacy and
the most favorable safety profile.
540

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Pamela S Meyers, MC
USA
Arthralgias, Paresthesias, Weakness, Oh My!: An Unusual Presentation Of Celiac Sprue
CPT Pamela S Meyers, MC USA Second Author: COL Leslie W. Jackson, MC USA
INTRODUCTION:We present the case of a 48-year-old female with known hypothyroidism who
presented to rheumatology clinic for evaluation of multiple complaints including arthralgias and fatigue
and later diagnosed with Celiac sprue.
CASE PRESENTATION: A 48-year-old female with a history of hypothyroidism presented to the
rheumatology clinic for evaluation of diffuse arthralgias and weakness in addition to paresthesias for 2
months. Other associated symptoms included an upper extremity tremor, lower extremity muscle
cramps and myoclonic jerking. Her medical history included a diagnosis of hypothyroidism and a
questionable demyelinating cranial lesion diagnosed in 2005 with subsequent normal lumbar puncture
and MRA in 2006. On exam the patient was noted to have a slight tremor of both hands and tenderness
to palpation of bilateral MCPs without swelling. Initial lab workup was significant for an iron deficiency
anemia, low vitamin D level, elevated ESR, 1:80 ANA, and elevated TSH. Hand radiographs showed
moderate generalized osteopenia, narrowing of the interphalangeal joints distally, and narrowing of the
first carpometacarpal joint. Iron deficiency anemia and transaminitis prompted a referral to GI for EGD
and colonoscopy. The EGD revealed villous flattening of the duodenum. Biopsies and celiac panel
confirmed the diagnosis of celiac disease. After 1 month on a gluten free diet, the paresthesias,
weakness, and arthralgias improved.
DISCUSSION: Celiac disease is a common disease that affects 1 in 300-500 people, generally of
Northern European descent. It is an autoimmune disorder characterized by villous atrophy of the small
intestine. Patients typically present with symptoms of malabsorption, such as steatorrhea or weight
loss. Some patients get the characteristic rash of dermatitis herpetiformis. As our case demonstrates,
they can also present with a variety of other symptoms, such as paresthesias, ataxia, depression,
arthralgias, and osteopenia from vitamin D deficiency. Initial workup of patient complaints often reveal
an iron deficiency anemia and transaminitis, as was the case with this patient. Additionally, the finding
of an elevated TSH as was seen in this patient with hypothyroidism is likely due to malabsorption of
levothyroxine. Diagnosis is suggested by EGD demonstrating villous flattening of the duodenum. Celiac
panel, including gliadin IgA and anti-TTG Ab, are also suggestive of this diagnosis. Celiac sprue generally
has a good response to a gluten free diet. However, there are refractory cases of sprue that require
glucocorticoids, azathioprine, or 6-mercaptopurine. Close followup is needed, as patients with Celiac
are at increased risk of malignancy, particularly non-Hodgkin’s lymphoma.
541

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Vanya Wagler, DO
Gynecomastia from Graves’: An Uncommon Cause of a Common Complaint
CPT Vanya Wagler, DO, MAJ Kimberly Rieniets, DO
INTRODUCTION:Graves’ disease is the most common cause of acquired hyperthyroidism and is due to
autoantibodies to the thyroid stimulating hormone (TSH) receptor. Multiple clinical presentations of
Graves’ disease are possible including typical manifestations of hyperthyroidism, along with frequent
opthalmopathy due to activation of T cells by TSH receptor antigen. We present a case of a 26-year-old
male who presented with gynecomastia and galactorrhea and was found have TSH autoantibodies
consistent with Graves’ disease. Gynecomastia and galactorrhea is a recognized but unusual initial
presentation of Graves’ disease.
CASE PRESENTATION: A previously healthy 26-year-old male active duty airmen presented to an
ambulatory primary care clinic for evaluation of painful and enlarging breast tissue bilaterally along with
clear nipple discharge. He also reported occasional palpitations and chest discomfort that interfered
with sleep. His physical exam was remarkable for normal vital signs, diffusely enlarged, nontender
thyroid gland, and bilateral gynecomastia. There was a slight resting tremor, and brisk but equal deep
tendon reflexes bilaterally. There was no exophthalmos or visual field deficit. He was subsequently
referred for cardiology evaluation and was found to have a normal EKG and echocardiogram. Thyroid
studies were obtained and were notable for TSH of 0.02 mcIU/mL and free T4 of 5.25 ng/dL consistent
with thyrotoxicosis. Beta-blocker was initiated and patient was referred for endocrine evaluation.
Further lab studies were notable for TSH receptor antibody level of 99.16 IU/L, and thyroid stimulating
immunoglobulin level 393% of control. Serum estradiol was elevated at 30 pg/L; estrogen was 180
pg/mL and estrone was 53 pg/mL. Prolactin and follicle stimulating hormone were 6.48 ng/mL and
7.07mIU/mL, respectively. Serum total testosterone was increased at 1669 ng/dL but bioavailable
testosterone was decreased at 75.8 ng/dL. HCG was undetectable. Thyroid ultrasound showed diffuse
enlargement with no focal lesions. Radioiodine uptake (RAIU) scan showed diffusely increased uptake of
79% at four hours consistent with Graves’ disease. After appropriate counseling, patient underwent I-
131 ablation without complication. He was started on levothyroxine 100 mcg daily, and had gradual
complete resolution of his presenting complaints including gynecomastia, galactorrhea, and
palpitations; TSH and free T4 also returned to normal.
DISCUSSION: Though gynecomastia is a relatively common finding in hyperthyroidism, there are few
published case reports of gynecomastia as the presenting complaint in Graves’ disease. Etiology of this
finding is thought to be due to an altered ratio of serum estradiol to testosterone, along with increased
levels of sex hormone binding globulin (SHBG). As a result, total testosterone level may be normal or
increased (as in our patient), but free testosterone is decreased.
542

US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Vanya Wagler, DO
More Than Meets the Eye: When SLE Surprises Us All
CPT Vanya Wagler, DO, MAJ Peter Henning, DO, LTC Michael Abel, MD
INTRODUCTION:Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disorder that can cause
significant morbidity and premature death. Presenting features often include fatigue, arthritis or
arthralgias, and typical skin findings, but the disease can affect essentially every organ system. We
present a case of a young female with SLE whose early disease course was characterized by lifethreatening
involvement of her lungs and GI tract. Definitive diagnosis was complicated by negative ANA
testing by ELISA until an alternative assay was used.
CASE PRESENTATION: An 18-year-old Hispanic female with a longstanding history of focal segmental
glomerulosclerosis treated with oral cyclophosphamide presented to establish medical care. She had
recently been hospitalized at an outside facility and given a presumptive diagnosis of Wegener’s
granulomatosis manifested by diffuse alveolar hemorrhage (DAH) and positive MPO
antibodies. Laboratory evaluation at our center was notable for MPO antibodies, lupus anticoagulant
and a single positive ANA using bead ELISA technology. Multiple subsequent ANA results were negative.
A paired blood sample was sent to Quest Diagnostics for fluorescent ANA testing which was positive at a
titer of 1:1280, and she was diagnosed with SLE. Over the next 4 months she required multiple hospital
admissions for recurrent DAH with a bland lung biopsy and superior mesenteric artery vasculitis causing
life-threatening GI bleeding. She was cumulatively treated with multiple pulses of IV
methylprednisolone, two courses of plasmapheresis, IV immune globulin, and combination rituximab
with IV cyclophosphamide. These treatments induced clinical remission. Her chronic kidney disease
progressed and she began hemodialysis (HD). Despite HD she had multiple episodes of volume overload
and hypertensive crisis with seizures. During an episode of hypertensive crisis she developed mental
status changes with bilateral cortical blindness. Brain MRI revealed diffuse white matter changes
involving the cerebellum and posterior cerebrum consistent with reversible posterior
leukoencephalopathy syndrome (RPLS). With aggressive medical management and kidney ablation with
selective renal artery embolization, she regained blood pressure control with a resolution of cortical
blindness. Subsequent MRI imaging showed dramatic resolution of the previous findings.
DISCUSSION: Our patient illustrates that a broad range of initial presentations is possible in SLE.
Although she did not have the more common complaints of arthralgias or rash initially, she had severe
involvement of her lungs and GI tract requiring aggressive, multi-modal treatment. Previously published
case reports have documented episodes of RPLS in association with SLE. Fluorescent ANA testing
remains the gold standard. In patients with a high clinical suspicion for SLE, but negative ANA using
ELISA technology, immunofluorescent ANA testing should be considered.
543

US NAVY POSTER FINALIST - CLINICAL VIGNETTE Caitlin M O'Connor, MD
Salmonella Strikes Again: Case of Salmonella heidelburg Wound Infection
LT Caitlin O’Connor, MC, USN (Associate) and LCDR Jennifer Curry, MC, USN (Member) Naval Medical
Center, Portsmouth, VA.
INTRODUCTION: A major risk of prosthetic implant surgeries is the potential for development of a
hardware infection. Bacteria that commonly infect the bones and soft tissue can form a biofilm on
hardware making their identification difficult and their eradication even more complicated. One of
these biofilm producing bacterial species is Salmonella. Non-typhoidal Salmonella (NTS) species are
important food borne pathogens usually resulting in gastroenteritis. However 7-12% of NTS infections
extend beyond the gastrointestinal tract causing bacteremia or focal suppurative
infection. Immuncompromised patients are more susceptible to developing bacteremia or focal
infection. We present a case of Salmonella heidelburg infection in an adult male with spindle cell
carcinoma following radical resection and hardware placement.
CASE PRESENTATION: Our patient is a 39-year-old male diagnosed with spindle cell sarcoma in the
proximal left tibia. The lesion was resected and a Stryker modular rotating hinged knee, an Omnifit
distal cement spacer with rotating hinges, and tibial insert were placed. Two months later, several
members of the patient’s family developed a self-limited gastroenteritis. The patient was not afflicted
with vomiting or diarrhea, but he did note the new onset of heartburn. One week following resolution of
these symptoms, he had left knee pain, swelling, and erythema. He underwent an incision and drainage,
with extensive purulence noted in the soft tissue surrounding the left knee and involving the internal
hardware. A partial hardware exchange was performed utilizing tobramycin impregnated cement, and
he was empirically started on vancomycin and piperacillin/tazobactam. Wound cultures (5 of 5) were
positive for Salmonella heidelburg. The patient’s antibiotic therapy was transitioned to ciprofloxacin and
azithromycin. He subsequently developed a prolonged QT, and antibiotics were changed to
ciprofloxacin and trimethoprim-sulfamethoxazole. The patient is in remission 9 months status-post
resection. He remains on long term antibiotic therapy.
DISCUSSION: Immunocompromised patients are at increased risk for developing suppurative
complications of NTS infections. They often develop focal soft tissue Salmonella infections in the
absence of gastrointestinal symptoms, similar to this patient. His case was complicated by the inability
to fully remove the infected hardware and associated biofilm, thus a prolonged course of suppressive
antibiotics was required. Historically Salmonella infections were treated with chloramphenicol,
ampicillin, or co-trimoxazole. However, due to a rise in antibiotic resistant Salmonella, fluoroquinolones
and extended-spectrum cephalosporins are now used as empiric alternatives. Emergence of resistance
has been seen with prolonged antibiotic therapy, prompting our use of a dual antibiotic regimen. It is
imperative to recognize uncommon bacteria causing life-threatening infections in the
immunocomprised and appreciate the difficulties in treating these infections with long-term antibiotics.
544

US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Geoffrey J Cole, MD
That's a "Rap": A Novel Use of Sirolimus to Prevent In-stent Restenosis After PCI in a Patient with
Pseudoxanthoma Elasticum
LT Geoffrey J Cole, MD, Second Author: LT Rolf Graning, MD, Third Author: LTC Matthew Jezior, MD
INTRODUCTION: Pseudoxanthoma elasticum (PXE) is a rare inherited disorder due to a loss of function
in the ABCC6 gene resulting in degeneration and calcification of elastic fibers. PXE is clinically expressed
with cutaneous, ophthalmologic, and cardiovascular sequelae to include premature
atherosclerosis. This case involves a novel use of sirolimus to prevent early in-stent restenosis (ISR) after
percutaneous coronary intervention (PCI) with drug eluting stents (DES).
CASE PRESENTATION: A 55 year old male with a history PXE presented to cardiology with a complaint
of angina. Exercise treadmill testing revealed ischemic electrocardiogram (ECG) changes to include a run
of ventricular tachycardia as well as reproduction of chest pain. Subsequent left heart catheterization
(LHC) showed severe, obstructive three vessel disease and the patient underwent four vessel surgical
revascularization. The patient had an uncomplicated post operative course, but was found to have poor
functional capacity, chest pain, and ischemic ECG changes on routine stress testing prior to cardiac
rehab enrollment. Subsequent LHC showed complete occlusion of all four bypass grafts. He then
underwent staged PCI with a total of seven DES deployed with relief of symptoms. Within 6 months the
patient had recurrent index angina requiring repeat LHC which showed rapid ISR of the majority of the
previously placed stents. The patient again underwent PCI with placement of multiple DES which again
resulted in significant ISR within seven months. Due to recurrent rapid ISR the patient was given a load
of oral sirolimus in addition to PCI with DES deployed in two vessels followed by maintenance dosing of
oral sirolimus for 30 days post intervention in addition to dual anti-platelet therapy. The patient
underwent subsequent LHC approximately one year after systemic sirolimus due to atypical chest pain
which showed widely patent stents.
DISCUSSION: PXE is a rare, inherited disorder characterized pathologically by progressive degeneration
and calcification of the elastic fibers found primarily in the skin, eyes, and cardiovascular system with
a highly variable phenotypic expression. The internal elastic lamina of medium sized arteries is often
involved in PXE which leads to premature atherosclerosis due to calcification. The atheroma that is
formed is histologically indistinguishable from other causes such as smoking, hypertension and
hyperlipidemia. This case is unique due to the rapid failure of the bypass grafts and rapid recurrent ISR
which we hypothesize is secondary to the underlying pathophysiology of PXE. This case is also unique as
systemic sirolimus has been shown to be effective for prevention of ISR when used with bare metal
stents but its use has not been reported in the medical literature with DES.
545

US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Priti Nath, MD
Bloom where you are planted: Treatment Toxicity of Bloom’s Syndrome in a 46 year old woman.
LT Priti Nath, MD Second author: John Nelson MD Third Author: Karen Bullock Russell MD (Member)
INTRODUCTION: Bloom’s Syndrome is a rare autosomal recessive genetic disorder of the BLM gene
yielding genomic instability due to mutation in DNA helicases and resultant chromosomal
breaks. Manifestations include growth retardation, cranio-facial dysmorphic features,
immunodeficiency and increased risk of fatal cancers. The mean age of incident malignancy and
mortality is 25. There are only 265 registered patients worldwide. We report a case of a 46 year old
woman with Bloom’s Syndrome presenting with a base of tongue (BOT) squamous cell carcinoma. Her
treatment plan, management, and toxicity will be discussed.
CASE PRESENTATION: LD is a 46 year old female with type II diabetes and no history of prior cancer.
She initially presented with right otalgia and recurrent otitis followed by progressive pain and dysphagia.
During fiber optic laryngoscopy, a right BOT biopsy revealed a primary squamous cell carcinoma, and
PET-CT confirmed stage IVa: clinical T4N2cM0. Concurrent chemoradiotherapy was planned, with
cisplatin at 30 mg/m 2 /week for curative intent due to her young age and questionable activity of
cetuximab given her underlying Bloom’s. On Day 7 of radiation and one dose of cisplatin, the patient
was hospitalized with emesis, fever, and severe confluent oropharyngeal mucositis. Her absolute
neutrophil count on admission was 1170 c/dl, with hemoglobin 8 g/dl and platelet count 195
1000x/ul. Multiple transfusions and addition of G-CSF were required due to progressive pancytopenia,
with count nadir on Day 17. Cisplatin was withheld, though RT was continued to a total goal dose of
7020 cGy. With count recovery, she received her second and final dose of cisplatin on Day 30 at only
5mg/m 2 , and again developed severe neutropenia with fever. She required tracheotomy and recurrent
critical care for management of subsequent epiglottitis with persistent secretions and MRSA
pneumonia. Restaging PET-CT is pending.
DISCUSSION: It is remarkable that LD developed her first malignancy in the 4 th decade of life. Based on
one case report with Bloom’s and subsequent head and neck carcinoma in the literature, curative
chemoradiotherapy was designed with concern for increased likelihood of toxicity, with lower doses of
cisplatin (30 mg/m2, 5 mg/m2) given weekly instead of every four weeks (100 mg/m2). LD
demonstrated evidence of mucositis and severe pancytopenia, despite normal renal function, at week 2
of treatment. While most patients develop mucositis with RT, this is usually after week 4; mild
cytopenias are rarely seen with cisplatin. It is likely that her underlying Bloom’s DNA repair defect
yielded prolonged cell turnover and bone marrow suppression, even with minimal cytotoxic
chemotherapy. Patients with Bloom’s Syndrome should have age appropriate cancer screening to
diagnose malignancy at an earlier stage for optimal outcome and decreased need for chemotherapy and
radiation. Curative oncology treatment can be given as indicated, with expectation of exquisite and early
toxicity.
546

US NAVY POSTER FINALIST - CLINICAL VIGNETTE Edward Thomas Stickle, Jr
MD
Fulminant reactivation hepatitis b with unsupervised sirolimus immunosupression for autologous
kidney transplant
Edward Thomas Stickle, Jr MD Second Author: Darren B Keller, MD
INTRODUCTION: Immune suppression after organ transplant must balance rejection prophylaxis with
adequate host immunologic defense. Each agent in use today also has a unique side effect
profile. Sirolimus has gained popularity in allographic kidney transplant due to reduced nephrotoxic
effects compared to other agents. However, reactivation of prior infection, including hepatitis B, results
in significant morbidity and mortality. To our knowledge, this is the first reported case of reactivation
hepatitis B in conjunction with sirolimus therapy.
CASE PRESENTATION: A 48 year old man who underwent autologous kidney transplant four years
prior was referred to gastroenterology for jaundice, fatigue, and elevated liver enzymes. Pre-transplant
screening was notable for non-reactive hepatitis B surface antigen and reactive hepatitis B core
antibody. Immune suppression regimen was sirolimus 3mg and prednisone 7.5mg daily. One week
prior to presentation, he developed anuria. Evaluation was notable for jaundice, hyperbilirubinemia
(12.2 mg/dL), and elevated transaminases (AST 368 IU/L, ALT 254 IU/L), and INR of 2.8. Abdominal
ultrasound demonstrated moderate ascites, hepatomegaly, without common bile duct
dilatation. Repeat serology demonstrated reactive hepatitis B surface antigen, and viral load greater
than 200,000,000 IU/ml. The patient was admitted to a nearby transplant center for reactivation
hepatitis B, had a six-week intensive care stay, and died two days post liver transplant.
DISCUSSION: Hepatitis B globally affects one-third of the population; exposure alone confers risk of
reactivation in an immune compromised host. Positive hepatitis B core antibody status implies
exposure to hepatitis B, but not active infection. Hepatitis B may persist in the reticuloendothelial
system as covalently closed circular DNA. Sirolimus binds the rapamycin mTOR receptor, inhibiting cell
cycle progression of developing T-cells, suppressing the adaptive immune response and inhibiting
clearance of hepatitis B virus. Recommended sirolimus serum values during therapy are less than 10
ng/ml. This patient was noted to be supratherapeutic during his treatment, with values of 78.2 and 43.4
prior to presentation. This is thought to be significant, although to what degree is unknown, as viral
load was not monitored during treatment. Our hypothesis is over suppression allowed reactivation of
latent hepatitis B, while reconstitution of the immune system and recognition of disease ultimately led
to fulminant liver failure. Acute viral hepatitis, whether de novo infection or reactivation, can rapidly
escalate to an emergency. One must minimize these risks both pre and post-transplant, with screening
including both hepatitis B surface and core antibody as well as surface antigen. Unexposed hosts should
be vaccinated for primary prevention pre-transplant. Positive hepatitis B core antibody should incite
close monitoring for reactivation. Post-transplant; sirolimus levels must be closely monitored, as
elevated levels may be associated with reactivation of latent hepatitis B. Liver function tests should be
monitored as they may herald reactivation of latent infection and prompt immediate evaluation of
hepatitis B status and viral loads. Reactivation hepatitis B may rapidly lead to fulminant hepatic failure,
and must quickly be recognized.
547

US NAVY POSTER FINALIST - CLINICAL VIGNETTE Eric T Meek, MD
THE TRAPS OF MISSING THE BIG PICTURE
LT Eric T. Meek, MC, USN and CDR Rachel U. Lee, MC, USN. Naval Medical Center, Portsmouth, VA
INTRODUCTION:Recurrent fevers can be caused by infectious, neoplastic and rheumatologic
conditions. Auto-inflammatory diseases, also known as periodic fever syndromes, are inherited diseases
that can present with recurrent fevers and are often misdiagnosed for years because they present with a
vague constellation of symptoms masquerading as other diseases.
CASE PRESENTATION: The patient is a 42 year old male presenting with a history of recurring episodes
of fevers and severe abdominal pain. The onset of symptoms acutely started with abdominal pain
progressing to include pleurisy, night sweats, malaise, and anorexia with about a 15 pound weight
loss. He denied any focal myalgia, conjunctivitis/periorbital edema, or rash. His symptoms occur 1 -2
times per year lasting 1 - 3 weeks. Over the years, the patient has presented to sick call, many
emergency rooms, and multiple specialists. The typical work-ups he received of colonoscopies and CT
scans of his abdomen were normal, and CT scans of his chest were without any pulmonary
emboli. Laboratory evaluations often showed elevated inflammatory markers with his CRP 63.5 and ESR
58 and a mild normocytic anemia with no leukocytosis. However, extensive tests for pancreatitis,
cholecystitis, appendicitis, and other inflammatory conditions were normal. A further history of the
patient, coincidentally, revealed that his father, uncle, and identical twin 9 year old sons had similar
symptoms. Due to the constellation of symptoms, family history, and their Irish background, genetic
testing was performed on the father and his sons for the TNFRSF1A gene. Both the father and his twin
sons had a heterozygous mutation at 102Y consistent with TNF-Receptor Associated Periodic Fever
Syndrome (TRAPS), previously known as Familial Hibernian Fever.
DISCUSSION: Inherited periodic fever syndromes include Familial Mediterranean Fever, Hyper-IgD
syndrome, Familial Cold Autoinflammatory Syndrome, Muckle Wells Syndrome and TRAPS. TRAPS is an
autosomal dominant disease that was first described in an Irish family in 1982 due to a mutation in the
TNFRSF1A Gene. Diagnosis is made by genetic testing and treatment is aimed at decreasing
inflammation with corticosteroids, anti-TNF therapy (entanercept) or anti-IL-1 receptor (anakinra).
Prognosis is good with treatment and less then 25% will develop amyloidosis. This case demonstrates a
patient presenting with common symptoms of an unusual disease. A thorough family history may have
accelerated his diagnosis and hastened proper treatment for this patient and his family members. His
course since diagnosis has been unremarkable with the administration of prednisone. He required this
treatment 2-3 times (2-3 days of therapy) in the past year each with excellent results. As is the case
with incomplete penetrance, one of his sons had more severe and frequent symptoms and required
entanercept 50mg weekly but has had no reocurrence over the past year. The views expressed in this
article are those of the author(s) and do not necessarily reflect the official policy or position of the
Department of the Navy, Department of Defense or the United States Government. I am a military
service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that
‘Copyright protection under this title is not available for any work of the United States
Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a
military service member or employee of the United States Government as part of that person’s official
duties.
548

US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Haydar M Al-Eid, MD
Drinking In The Groove! one Rare Form Of Pancreatitis: A Case Report And Review Of Literature.
LT Haydar M Al-Eid, MD
INTRODUCTION:Groove pancreatitis is a rare form of segmental chronic pancreatitis characterized by
fibrous scars of the anatomic space between the dorso-cranial part of the head of the pancreas, the
duodenum, and the common bile duct. We report a case of a male patient with a pancreatic mass who
underwent pancreaticodoudenectomy with transverse colon resection and colo-colonic anastamosis.
The mass was subsequently diagnosed as groove pancreatitis.
CASE PRESENTATION: A 46 year-old alcoholic male presented with postprandial epigastric pain,
nausea, vomiting, and a few episodes of coffee ground emesis for 12 hours duration. He also had prior
history of lightheadedness and weight loss over the past few months. He was initially evaluated for
acute pancreatitis. Serum Lipase was 1352U/L (normal 23-300 U/L). CT scan followed by
esophagogastroduodenoscopy (EGD) showed a pancreatic mass at the head of the pancreas which was
bulging into and obstructing the pyloric outlet. Patient underwent a pancreaticodoudenectomy
(Whipple’s) surgery during which the pancreatic mass was found to have invaded the mesentery which
led to partial transverse colon resection and colo-colonic anastamosis. It was at this time that the frozen
section pathology was read as consistent with groove pancreatitis. Post-operative course was
complicated by bleeding which was treated conservatively. He subsequently had large NG tube output
which led to a CT scan revealing a jeujenal obstruction. The patient underwent an exploratory
laparotomy, internal hernia reduction, and J-tube placement. The second postoperative course was
unremarkable. At discharge, patient was asymptomatic, afebrile, ambulating, and his post-operative
pain was adequately controlled. The patient was seen one week after discharge and was doing well.
DISCUSSION: Groove pancreatitis, although rare, is often diagnosed in 40 to 50 year-old alcoholic
men. Clinical presentation is usually postprandial abdominal pain and impaired motility. These patients
often have duodenal stenosis and postprandial vomiting which leads to significant weight loss. Jaundice,
however, is unusual. The duration of the clinical symptoms may range from a few weeks to more than
one year.
Conclusion
Groove pancreatitis often masquerades as pancreatic head carcinoma. This condition -although it is
rare- should be kept in mind when making the differential diagnosis between pancreatic masses and
duodenal stenosis. In all cases of focal pancreatitis involving the head or the uncinate process of the
pancreas with involvement of the adjacent viscera (commonly, the pylorus of the stomach or the
duodenum), the possibility of groove pancreatitis should be highly considered.
549

US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Michael James E Monson,
DO MA
Elevated Intracranial Pressure Diagnosed by Optic Ultrasound in the Setting of Normal Intraventricular
Catheter Pressure Measurements.
Dr. Michael Monson D.O., M.A. Dr. Anthony Nations M.D.
INTRODUCTION: One of the largest obstacles for physicians treating wounded service members is
measuring intracranial pressure (ICP). Intraventricular catheters have long served as the “gold standard”
of measuring, but are extremely invasive and difficult to maintain. Recent studies have shown that
ultrasound measurement of the optic nerve sheath diameter can be used as a noninvasive way to gauge
the ICP. This includes studies by Hansen HC, Blaivas M, Tayal V, Moretti R, who have come to the
conclusion that ultrasound can consistently evaluate for an increased ICP. We present the case of a
wounded Marine who was diagnosed by ultrasound to have elevated ICP, in the setting of a normal
intraventricular catheter pressure measurement.
CASE PRESENTATION: The patient is a 20 year old previously healthy male who was injured in an
explosion causing multiple penetrating cranial wounds. Prior to transfer to our facility, he had
undergone multiple surgeries in Afghanistan and Germany, including a bifrontal craniectomy with
intraventricular catheter placement for direct ICP monitoring. One week after arrival, the patient
became acutely hypertensive and bradycardic, concerning for increasing ICP manifesting as Cushing’s
Reflex. The reading from the intraventricular catheter was discordant, however, showing a normal
pressure. To assess help solve this diagnostic dilemma, a bedside ultrasound was performed of the orbit,
which showed a markedly dilated optic nerve sheath diameter (6.9mm with normal being less than
5.2mm). The patient was taken for a stat CT of the head, which showed a significant increase in size of a
previously stable intracranial hemorrhage. He was taken for arterial embolization, which he tolerated
without complication. The intraventricular catheter did eventually show an elevated ICP, but not for
another 2 hours.
DISCUSSION: This case highlights the profound usefulness of the bedside ultrasound as a diagnostic
modality in patients who have suffered traumatic brain injury. As military physicians who are constantly
involved with the care of the Wounded Warriors, this is a rapidly available test that can provide a great
deal of information. In this patient, whose vital signs and physical exam findings were conflicting, beside
ultrasound of the optic nerve sheath was able to provide information leading to a definitive diagnosis
prior to the “gold standard” of direct ICP measurement. We submit this case to bring to the attention of
military physicians the usefulness of a bedside ultrasound of the optic nerve sheath as a means to
evaluate for increased intracranial pressure.
550

UTAH POSTER FINALIST - CLINICAL VIGNETTE Craig D Robison
Not-So-"Idiopathic" Thrombocytopenia: Uncommon or Under-Recognized Reaction to a Common
Drug?
; Craig D. Robison, MD (1,2) Mustafa Mir-Kasimov, MD (1,2) (1) Department of Internal Medicine,
University of Utah School of Medicine, Salt Lake City, Utah (2) George E. Wahlen Department of
Veterans Affairs Medical Center, Salt Lake City, Utah
INTRODUCTION: Drug-induced thrombocytopenia is a reversible cause of thrombocytopenia that is
commonly not diagnosed. Diagnosis requires high level of clinical suspicion, correlation with the
initiation of suspect drug, reversibility once the offending drug is stopped, and, ideally, laboratory
confirmation. However, routine laboratory methods of diagnosis are not readily available and the
diagnosis is frequently overlooked and under-reported in literature.
CASE PRESENTATION: DISCUSSION: Thrombocytopenia in the hospitalized patient has many
etiologies. This case emphasizes a potentially frequently under-recognized acquired etiology for
thrombocytopenia from a commonly utilized antimicrobial. High clinical suspicion and careful history
taking and chart review can possibly save patients from unnecessary transfusions with associated risks
as well as costly pharmaceutical interventions.
551

VERMONT POSTER FINALIST - CLINICAL VIGNETTE Mitchell L Nimmich, MD
Novel Therapy for Unresectable Cutaneous Squamous Cell Carcinoma in a Somali Male with
Oculocutaneous Albinism
Mitchell Nimmich MD, Patrick Hohl DO, MPH
INTRODUCTION: Novel Therapy for Unresectable Cutaneous Squamous Cell Carcinoma in a Somali
Male with Oculocutaneous Albinism. Mitchell Nimmich, MD and Patrick Hohl, DO, MPH. University of
Vermont / FAHC Internal Medicine Residency Program, Burlington, VT.
CASE PRESENTATION: MI is a 25 year-old black male who recently emigrated from Somalia with a past
medical history significant for oculocutaneous albinism presenting for evaluation of bilateral scalp and
neck masses. These originally began as small skin lesions 2-3 years prior to presentation and progressed
to the point of unilateral vision impairment. He came to the United States via a Kenyan refugee camp,
arriving in Nashville, TN where he was evaluated at an area hospital. Initial biopsy showed poorly
differentiated carcinoma. He left that hospital shortly after presentation to pursue further workup in
Vermont, where his closest family members were located. On arrival he was admitted to the oncology
service and underwent a second biopsy, which showed poorly differentiated squamous cell
carcinoma. CT head showed the mass extending into the external auditory canals but no skeletal or
cerebral invasion. Both scalp masses appeared infected and he was initially treated with pipercillintazobactam
and vancomycin. Otolaryngology and radiation oncology were consulted. Given the
vascular nature of the masses and their large size, surgical resection was deemed too risky. Radiation
oncology was hesitant to administer radiation therapy given his albinism and risk for inciting subsequent
tumors. Staging workup with CT chest, abdomen and pelvis did not reveal metastasis. He did not show
signs of systemic infection, therefore his antibiotics were changed to topical metronidazole powder with
good response. He was treated with four cycles of cisplatin and cituximab with no effect on tumor size.
He was treated with palliative radiation (underwent radiotherapy for two weeks with daily dose
fractions of 300 Gy, total dose of 3000 Gy) and daily dexamethasone and was discharged to hospice. He
showed a dramatic response to radiation and had an almost complete resolution of tumor mass. He
was subsequently discharged from hospice and continues to be followed closely by oncology, radiation
oncology and dermatology. He does have several new scalp lesions that appear to be novel squamous
cell carcinomas in addition to multiple actinic keratoses.
DISCUSSION: Cutaneous squamous cell carcinoma is a malignant proliferation of epidermal
keratinocytes. Major risk factors are cumulative sun exposure (higher near the equator) and
age. Oculocutaneous albinism is an independent risk factor with a 25% prevalence of non-melanoma
skin cancer (including basal cell carcinoma and squamous cell carcinoma). According to NCCN
guidelines, treatment of early non-invasive SCC consists of surgical resection, with radiation therapy
reserved for invasive lesions or larger, non-resectable disease. Systemic chemotherapy is typically
reserved for metastatic disease and an effective regimen has been gleaned from only a few small case
reports. Even fewer case reports exist for invasive SCC in albino patients residing in equatorial Africa.
Among this high-risk population primary treatment typically consists of surgical resection with adjuvant
radiotherapy, but treatment choices are often influence by resource availability in these locations.
Systemic chemotherapy agents, including cisplatin and more recently the newer agent cituximab, an
antibody targeted against epidermal growth factor receptor (EGFR), have been used with limited
success. Typically these are used to reduce tumor size so that the more effective surgical or radiation
techniques can be applied.
552

VERMONT POSTER FINALIST - CLINICAL VIGNETTE Elizabeth B Nimmich, MD
Community-acquired MRSA epidural abscess and meningitis Elizabeth Nimmich MD, Anne Bantle MD
Fletcher Allen Healthcare/University of Vermont Internal Medicine Residency Program, Burlington, VT
Elizabeth B Nimmich, MD Second Author: Anne Bantle, MD
INTRODUCTION: Incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-
MRSA) has increased since its first description in the literature in the 1980s. Less common are reports of
CA-MRSA with central nervous system (CNS) involvement, with only a small number of cases published
since 1999. Given the restrictive permeability of the blood-brain-barrier to certain antibiotics, treatment
of CNS CA-MRSA infections can pose a significant challenge. Unfortunately, these infections also carry a
considerably high mortality.
CASE PRESENTATION: A 25 year old woman with past medical history significant for intravenous
heroin abuse presented with a 2-3 day history of progressively worsening neck and back pain and a one
day history of dyspnea and fever. Pertinent physical exam findings included temperature of 38.1°C,
pulse 140, hypoxia on room air, left-sided paraspinal muscle tenderness to palpation, positive Kernig’s
sign, and left-sided neck swelling and erythema. She was empirically started on ceftriaxone 2 g IV BID,
vancomycin 15 mg/kg IV TID, and gentamicin 1mg/kg IV TID. A lumbar puncture was performed and was
notable for an opening pressure of 35 mmHg, WBC 230 with 98% neutrophils, protein 406, and glucose
49. MRI spine showed an epidural abscess extending from C7 to T7. Debridement of the epidural
abscess was planned. Blood cultures grew MRSA in 3/4 bottles. She continued to decline with rapidly
dropping platelet count, hypotension despite multiple vasopressors, and worsening hypoxia on
mechanical ventilation. On hospital day two, she developed wide-complex tachycardia, then pulseless
electrical activity, and expired despite resuscitative efforts with ACLS protocol.
DISCUSSION: This case represents the high mortality associated with hematogenous spread of CA-
MRSA to CNS. Though there are only a small number of similar cases reported in the literature, this may
represent a rise in severe CA-MRSA infection, similar to the trend with hospital-acquired MRSA in the
recent past. CA-MRSA has already been identified as the most common cause of skin and soft-tissue
infections in the emergency department. Treatment of severe CA-MRSA infection can be challenging,
and in early 2011 the Infectious Diseases Society of America’s new MRSA treatment guidelines added
linezolid and trimethoprim-sulfamethoxazole as alternatives to vancomycin for MRSA meningitis.
Vancomycin remains first-line therapy, but its reduced penetration through the blood-brain-barrier
limits is utility in cases such as this one. Interestingly, there are cases in the literature that show less
mortality associated with linezolid treatment. Given the smaller number of reports, this data is largely
anecdotal but poses a fascinating question over the appropriate antimicrobial selection in CA-MRSA CNS
infections and necessitates further evaluation.
553

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Vince Faridani, MD
Intrathecal Methotrexate Nephrotoxicity
Vince Faridani MD, Jim Mertz MD
INTRODUCTION: We are reporting a patient who presented with acute renal failure secondary to
intrathecal methotrexate administration for treatment of acute lymphoblastic leukemia (ALL). This
occurred despite normal renal function prior to methotrexate (MTX) initiation and vigorous hydration
with urinary alkalinization during treatment.
CASE PRESENTATION: A 47 year-old Hispanic gentleman presented to our hospital complaining of
generalized fatigue and lower extremity rash. Laboratory data disclosed a complete blood cell count
with a WBC of 1.6, PLT < 61,000, HCT 40.9%, HGB 14.4 g/dl. Serum urea was 14 mg/dl, serum creatinine
.9 mg/dL, sodium 134 mmol/L and bicarbonate 27 mmol/L. Bone marrow biopsy showed a hypercellular
bone marrow (90%) and left shift with increased blast cells (nearly 100%) compatible with ALL. Our
patient received his second course of cyclophosphamide, vincristine, doxorubicin and dexamethasone
and intrathecal methotrexate. The following day creatinine increased to 2.5mg/dl, serum uric acid level
was 10.6 mg/dL, methotrexate level was 23.56 µM. Thus confirming our suspicion of tumor lysis
syndrome. He was treated with intravenous hydration, alkalinization of the urine, and supportive
therapy with intensive leucovorin for 12 days. The patients renal function slowly improved, creatinine
returned to baseline and methotrexate and uric acid level returned to normal.
DISCUSSION: This is the 2 nd case report that illustrates a previously unrecognized potential
complication of intrathecal methotrexate -- acute tumor lysis syndrome. Despite normal baseline
creatinine clearance and adherence to standard precaution to prevent renal toxicity with hydration and
alkalinization, severe renal toxicity may occur secondary to tymor lysis syndrome. Development of acute
renal failure during methotrexate therapy is a medical emergency, since more than 90% MTX is cleared
by the kidneys, renal failure contributes to the sustained toxic levels of MTX. If not treated early and
aggressively, methotrexate can damage the ability of normal cells to synthesize DNA leading to cell
death and resulting in renal, hepatic, and central nervous system toxicity. As this case illustrates, even
with intrathecal methotrexate toxicity, treatment with pharmacologically guided leucovorin rescue
along with continuation of hydration and alkalinization will facilitate restoration of renal function and
decrease the risk of impending systemic toxicity.
554

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE LT Manoj Mathew, MD
A RARE CASE OF FALSELY ELEVATED THYROTROPIN(TSH)LEVEL DUE TO HETEROPHILE ANTIBODY
LT Manoj Mathew, MD
INTRODUCTION:Subclinical hypothyroidism, which is defined as elevated serum thyrotropin (TSH) and
normal serum free thyroxine (FT4) levels, is common clinical in practice. Patients with subclinical
hypothyroidism and TSH concentration above 10 mIU/L are usually treated with thyroid hormone
supplement. We hereby present a case in which heterophile antibodies interfere with the TSH assay,
leading to a falsely elevated TSH level and unnecessary thyroid hormone therapy.
CASE PRESENTATION: A 41 year-old female presented to her primary care physician (PCP) for an
annual physical examination. She reported no fatigue, temperature intolerance, or changes in her skin,
hair, or bowel habits. She had normal menstrual cycles and stable weight. The thyroid gland was normal
in size and without nodules. However, a screening thyroid panel (TFT) showed serum TSH level
19.6mIU/L (normal 0.465-4.680) and FT4 level 1.46ng/dL (normal 0.64-1.79). She was diagnosed with
subclinical hypothyroidism and started on levothyroxine treatment. Even though she was compliant with
the therapy, the TSH level remained elevated. Her PCP gradually increased the levothyroxine dosage to
300mcg daily. She subsequently developed palpitations and tremor and was referred to endocrinology
for further evaluation. Repeated laboratory study showed FT4 2.91ng/dL, FT3 1.7ng/mL (normal 0.970-
1.690), and TSH 17.7mIU/L. A Cosyntropin stimulation test showed the peaked cortisol level of
26.6mcg/dL (normal >18). TSH heterophile antibody was present. Endocrinology tapered and eventually
discontinued the levothyroxine treatment. The palpitations and tremor resolved. Subsequent study
showed TSH 22.9mIU/, FT3 1.11ng/mL, and FT4 0.80ng/mL. The TSH dilution test showed serum TSH
levels 15.2 mIU/L initially and 5.2 mIU/L after a five-fold dilution. With mouse serum pretreatment, the
TSH level was 1.19 mIU/L.
DISCUSSION: The differential diagnosis for elevated serum TSH with normal FT4 and FT3 includes
subclinical hypothyroidism, resistance to TSH, a TSH-secreting pituitary adenoma, untreated adrenal
insufficiency, and interfering substances. In our patient, subclinical hypothyroidism is unlikely given that
the TSH level never normalizes despite gradual increases in the levothyroxine dosage. Resistance to
thyroid hormone is unlikely given the normal TSH level in 2007 and absence of family history of thyroid
disease. A TSH secreting pituitary adenoma is also unlikely given the normal FT4 and FT3 levels and
absence of a thyroid goiter. Normal Cosyntropin stimulation makes adrenal insufficiency less likely.
The elevated TSH level in this patient is caused by human anti-mouse monoclonal antibodies (HAMA).
The TSH value normalizes when the serum is pretreated with mouse serum. HAMA, also known as
heterophile antibody, can interfere with TSH immunoassays, causing falsely elevated TSH values. Many
laboratories have HAMA-blocking reagents that can eliminate the interference of heterophile
antibodies.
Heterophile antibody interference with TSH immunoassay should be on the differential diagnosis of
asymptomatic patients with elevated TSH concentration. Evaluation for this condition may prevent
unnecessary thyroid hormone treatment.
555

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Sandra Moallem, MD
CHEST PAIN BY A BUG BITE
Sandra Moallem, MD Jennifer Ryal MD, – Eastern Virginia Medical School
INTRODUCTION:INTRODUCTION: Lyme disease is a multisystem disease caused by infection with
Borrelia burgdorferi. Cardiac involvement occurs during the early phase of the disease, usually within
weeks to a few months after the onset of infection. The most common clinical feature of Lyme carditis is
atrioventricular conduction block.
CASE PRESENTATION: Case: Mr. G is a 28 yo White male with no significant PMH who presented to the
ER during June with complaint of substernal chest pain for 3 days at rest, with no radiation, describe it as
a sharp pain, rate it 7/10, lasting for about 15 seconds with some residual soreness for 20-30 minutes.
Patient denied CP on exertion, deep inspiration or position changes. He also complained of shortness of
breath of same duration, associated with exertion. Pt worked as grounds keeper at a golf course and
denied any difficulty with his duty prior to symptoms started. He denied recent travel, camping, hacking
or sick contacts. Denied cocaine, tobacco and alcohol use. However he has previous history of marijuana
smoking. Four days prior, patient had an ER visit with complaint of fatigue and muscle aches and history
of insect bites in his left elbow and left calf. In the ER was diagnosed with cellulites and was discharge
home on clindamycin, bactrim. However patient continue to have intermittent fevers and chills,
erythematous rash on his face, night sweats, weight loss, lightheadedness, dizziness, nausea and diffuse
joint pain so he presented to the ER again. On admission patient was afebrile, HR 69, RR 20, BP 143/86
and Saturation 99% on RA. Patient was in NAD, with normal physical exam except a 1cm erythematous
lesion with black center in his elbow and calf. EKG showed normal sinus. CXR was unremarkable. Cardiac
enzymes were negative. CBC and CMP were normal. Pt was admitted to telemetry with atypical chest
pain. Given history of possible tick exposure tox screen, Lyme titers, RSMF, ECHO, and HIV test were
ordered and he was empirically treated with Ceftriaxone IV. Echo was Normal with EF 67%. PVL of LE
was negative. During hospitalization his symptoms improved. Patient was discharged home with empiric
treatment on CEFUROXIME PO for 21 days. After discharge, results of Lyme western blot were positive
confirming Lyme disease diagnoses.
INTRODUCTION: Lyme disease is a multisystem disease caused by infection with Borrelia burgdorferi.
Cardiac involvement occurs during the early phase of the disease, usually within weeks to a few months
after the onset of infection. The most common clinical feature of Lyme carditis is atrioventricular
conduction block.
Case: Mr. G is a 28 yo White male with no significant PMH who presented to the ER during June with
complaint of substernal chest pain for 3 days at rest, with no radiation, describe it as a sharp pain, rate it
7/10, lasting for about 15 seconds with some residual soreness for 20-30 minutes. Patient denied CP on
exertion, deep inspiration or position changes. He also complained of shortness of breath of same
duration, associated with exertion. Pt worked as grounds keeper at a golf course and denied any
difficulty with his duty prior to symptoms started. He denied recent travel, camping, hacking or sick
556

contacts. Denied cocaine, tobacco and alcohol use. However he has previous history of marijuana
smoking. Four days prior, patient had an ER visit with complaint of fatigue and muscle aches and history
of insect bites in his left elbow and left calf. In the ER was diagnosed with cellulites and was discharge
home on clindamycin, bactrim. However patient continue to have intermittent fevers and chills,
erythematous rash on his face, night sweats, weight loss, lightheadedness, dizziness, nausea and diffuse
joint pain so he presented to the ER again. On admission patient was afebrile, HR 69, RR 20, BP 143/86
and Saturation 99% on RA. Patient was in NAD, with normal physical exam except a 1cm erythematous
lesion with black center in his elbow and calf. EKG showed normal sinus. CXR was unremarkable. Cardiac
enzymes were negative. CBC and CMP were normal. Pt was admitted to telemetry with atypical chest
pain. Given history of possible tick exposure tox screen, Lyme titers, RSMF, ECHO, and HIV test were
ordered and he was empirically treated with Ceftriaxone IV. Echo was Normal with EF 67%. PVL of LE
was negative. During hospitalization his symptoms improved. Patient was discharged home with empiric
treatment on CEFUROXIME PO for 21 days. After discharge, results of Lyme western blot were positive
confirming Lyme disease diagnoses.
Discussion Carditis has been reported in 4 to 10 percent of untreated adults with Lyme disease in the
United States. However, several of these studies included palpitations as an indicator of carditis. More
objective features of carditis occurred in 3 percent of patients, or less. Patients with cardiac involvement
may be asymptomatic or complain of lightheadedness, syncope, shortness of breath, palpitations,
and/or chest pain.
DISCUSSION: DISCUSSION: Carditis has been reported in 4 to 10 percent of untreated adults with Lyme
disease in the United States. However, several of these studies included palpitations as an indicator of
carditis. More objective features of carditis occurred in 3 percent of patients, or less. Patients with
cardiac involvement may be asymptomatic or complain of lightheadedness, syncope, shortness of
breath, palpitations, and/or chest pain.
557

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Bonny Lauren Moore, MD
A High Tech Source of Ethylene Glycol Toxicity
Bonny Lauren Moore, MD Jadyn Swerbinsky, PA; James Cain, MD; Chad Demott, MD, FACP
INTRODUCTION:The patient's history of present illness is often the most important factor in making a
diagnosis. However, when a patient will not or cannot provide an accurate history, the differential
diagnosis must remain wide and empiric therapies often initiated without a firm diagnosis.
CASE PRESENTATION: A 20 yo man with no past medical history was admitted with vomiting, loss of
balance, and diplopia. He reported feeling well the night prior to presentation. He denied any ingestions
or inhalant use.
He presented afebrile with unremarkable vital signs. Neurologically, he exhibited truncal and peripheral
ataxia, bilateral dysmetria, and slowed speech with horizontal nystagmus on left gaze. Otherwise,
physical exam was unremarkable. At the outside hospital, BMP revealed a bicarb level of 11, chloride of
113, and BUN of 13. Initial creatinine of 1.09 and anion gap of 15 subsequently increased to 1.81 and 19.
Initial ABG showed pH of 7.21, pCO2 of 20 and pO2 of 118. CBC, creatine kinase, ammonia, and routine
toxicology were unremarkable. Serum ketones were not present. Imaging of head, abdomen, and pelvis
were unremarkable except for a distended bladder on CT. He had an osmolar gap of 30. Urine did not
fluoresce under Wood's lamp and the lab reported no calcium oxalate crystals, although on our exam,
calcium oxalate monohydrate crystals were present. Given the presentation, empiric fomepizole,
sodium bicarbonate, and CRRT were started. Ethylene glycol level drawn at our facility returned positive
at 12 mcg/mL. Other alcohol levels returned undetectable. The patient required hemodialysis for one
week before recovery.
He continued to deny toxic ingestions, even after a search of his bedroom revealed an open container of
computer coolant with a primary ingredient of ethylene glycol.
DISCUSSION: This case represented a diagnostic challenge: mixed metabolic acidosis with osmolar gap,
denial of ingestion, neurological complaints, and unusual findings on urinalysis. Calcium oxalate
monohydrate crystals are not as common as the dihydrate crystals, but can be detected in ethylene
glycol poisoning and are known to resemble picket fences as they are long, flat, hexagonal crystals.
While this case illustrates many important learning points, it is crucial to recognize the stages and
varieties of presentation for ethylene glycol poisoning.
Ethylene glycol is widely recognized as an ingredient in antifreeze for automobiles, but it is contained in
many common household products, such as computer coolant. This presentation is unusual as the
patient did not have a history of alcohol use or prior intoxication. To our knowledge, this is the first
reported case of ethylene glycol poisoning by computer coolant ingestion. Because of its wide
accessibility, early recognition and treatment of ingestion is critical.
558

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Seth T Parsons, MD
Cafe Au Lait With A Side Of Multiple Sclerosis
Seth T Parsons, MD Second Author: Sami G Tahhan, MD, FACP
INTRODUCTION: CASE PRESENTATION: A 32 y/o man came to the hospital with a two and a half
month history of worsening ataxia, limb numbness, tingling, weakness, diplopia and blurry vision. He
attested to multiple falls and had a positive Uhthoff’s sign. On exam, the patient had countless
cutaneous neurofibromas and café au lait spots. His cognitive function was slow and his speech was
slurred. MRI of the head and c-spine showed extensive cerebral, brainstem and cerebellar white matter
abnormalities with numerous enhancing lesions and extensive cord to upper thoracic cord signal
abnormalities consistent with multiple sclerosis. MRI of the orbits showed optic neuropathy also
consistent with multiple sclerosis. He was given 1 gram per day of methylprednisolone for five days and
received physical and occupational therapy which improved his strength and coordination.
DISCUSSION: Neurofibromatosis type 1 is a common autosomal-dominant neurocutaneous disorder
associated with café-au-lait spots, Lisch nodules, neurofibromatous tumors, and other pleotropic
conditions. Mutations of NF1 (a tumor suppressor gene located on chromosome 17q11.2) cause
functional loss of the protein neurofibromin, resulting in a wide-spectrum of the above said conditions.
Multiple Sclerosis is the most common autoimmune inflammatory demyelinating disease of the CNS,
characterized by multifocal areas of demyelination, astroglial scarring and loss of oligodendrocytes. It is
hypothesized that a genetic predisposition coupled with environmental triggers produces antibodies
directed against myelin, causing demyelination and a plethora of neurologic manifestations.
Reports have shown that the prevalence rates of Neurofibromatosis and Multiple Sclerosis co-existing
together are 15 times higher than expected separately. Theories for this association include: The NF1
gene encodes an important tumor suppressor protein called neurofibromin. Neurofibromin functions as
a suppressor by reducing cell proliferation through the p21 ras protein system. In NF1 patients, lack of
this crucial suppressor could result in over-proliferation, causing over-activity of the immune system and
abs against myelin. A second hypothesis involves oligodendrocyte myelin glycoprotein (OMgp) which is
embedded within intron 27b of the NF1 gene A. Oligodendrocyte myelin glycoprotein is essential for
myelination and the survival of myelinated axons. Any disruption to this gene could make it a target by
the immune system in genetically-predisposed MS patients, resulting in a massive demyelination
process. A third hypothesis involves Schwann cells which create myelin. Since NF1 is a proliferative
disorder involving these cells, it could be that overproduction of myelin causes an immune response
with ab production which then activates a similar response to CNS myelin.
More research is needed to clarify the causal relationship between MS and NF1, but this case illustrates
an interesting association.
559

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Chhayaben V Patel, MBBS
ACQUIRED FANCONI'S SYNDROME -- WATCH OUT IN HIV INFECTED PATIENTS WITH ACUTE RENAL
FAILURE ON TENOFOVIR
Chhayaben V Patel, MBBS Edward Oldfield, MD, Infectious disease, Eastern Virginia Medical School,
Norfolk, VA Hooman Sadr, MD, Nephrology Tidewater Kidney Specialists Inc, Norfolk, VA
INTRODUCTION:Tenofovir is a potent nucleotide reverse transcriptase inhibitor used in combination
with other antiretrovirals for the treatment of HIV infection since its introduction in 2001. It is now
increasingly recognized as a cause of Acquired Fanconi's Syndromre in HIV infected individuals. Several
case reports of acute renal failure and proximal tubulopathy have been reported with tenofovir use
since the first case report in 2003. We report a case of Fanconi's Syndrome that developed after more
than 8 years of tenofovir and reversed upon discontinuation.
CASE PRESENTATION: The patient is a 56 yo African American male with a CD4 of 616 cells/mm3 and
HIV RNA of 825 on emitricitabrine, tenofovir (started in 12/2002), atazanavir (started 1/2004). He
developed muscle weakness and presented with acute renal failure on admission on 7/1/11 with
creatinine of 2.6, GFR 34 (baseline 4/19/11 creatinine of 1.6, GFR 55 and stable since 2001) and with
glucosuria (1000 mg/dL with normal serum glucose), hypophosphatemia (Phos 1.0), hypokalemia
(potassium 2.9), proteinuria (100 mg/dL), serum uric acid 0f 1.7 mg/dl, urine creatinine of 22 mg/dl and
urine uric acid of 14 mg/dL. These are classic features of Acquired Fanconi Syndrome. Metabolic Acidosis
was not present due to concomitant metabolic alkalosis from emesis. On discontinuation of tenofovir
and replacement of electrolytes, clinical improvement with near normalization of electrolytes and return
of creatinine to baseline was seen within 5 weeks.
DISCUSSION: With tenofovir so commonly used in the treatment of HIV, urinalysis, renal and electrolyte
monitoring at regular intervals following its initiation should be considered. Current guidelines
recommend adjusting the tenofovir dose with CrCl < 49 mL/min., which this patient did not manifest
prior to developing Fanconi's syndrome. Given our experience with this patient, changing to a different
antiretroviral might be considered rather than continuing tenofovir or adjusting the dose if renal
insufficiency develops to decrease the risk of acquired Fanconi's syndrome. And also noted is that some
people assume Tenofovir induced fanconi's happens few months after initiation of therapy (avg 5
months) but this case shows that it can happen anytime (8 years later)
560

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Om Samantray, MD
Radial Artery Sterile Granulomatous Reaction
Om Samantray, MD Dexter De Leon M.D Gary Swank M.D M. Ayoub Mirza M.D
INTRODUCTION: Trans-radial cardiac catheterization was introduced in late 1980s and since then has
become increasingly popular due to lower risk of vascular complication, better patient comfort, lower
procedure costs and lesser duration of hospitalization. Despite all these advantage there are some
reported cases of radial artery granulomatous reaction associated with radial artery catherization. We
are presenting a case of radial artery granulomatous formation after trans-radial cardiac catheterization
CASE PRESENTATION: 55 year old male referred for diagnostic cardiac catheterization due to chest
pain which resulted in an abnormal myocardial perfusion scan demonstrating inferior wall ischemia. A
trans-radial cardiac catheterization was performed using a 5F Cook hydrophilic sheath. At the end of the
procedure a radial compression device was applied for hemostasis. Two weeks later, patient presented
with a painful erythematous, indurated, fluctuant nodule over the radial artery access site. He did not
have any signs or symptoms of systemic infection. He saw a dermatologist who performed incision and
drainage of purulent fluid. The fluid grams stain and culture was negative. Vascular duplex ultrasound of
radial artery was normal. He was treated with Prednisone 30mg daily for 5 days. There was complete
resolution within 3 weeks.
DISCUSSION: In the early years of cardiac angiography, most procedures were done through brachial
cut downs. In 1989, Campeau proposed Trans-radial approach for cardiac catheterization. Trans-radial
access is associated with lower vascular and bleeding complications and allows early patient ambulation.
The leading drawback to this approach is arterial vasospasm. To overcome vasospasm, a hydrophilic
lubricated catheter was introduced. Rathore et al. reported that this hydrophilic coating is effective in
reducing spasm and reduced patient discomfort.
Despite all of these advantages there are several reported case of sterile granulomatous reaction. Sterile
granulomas were commonly misdiagnosed as an infected pseudoaneurym, thrombosis or abscesses
leading to untoward surgeries and antibiotic treatments. Biopsy of these lesions reveals a suppurative
granulomatous reaction with macrophages containing a blue gray substance on stain microscopy. These
sterile abscess and granulomas typically have a benign course and in the absence of fever and
leukocytosis, the recommendation is observation. Since the cook hydrophilic sheaths were replaced in
our cardiac catherization lab and we have not seen any further cases of sterile granuloma of the radial
artery. The authors believe the sterile granuloma appear due to a foreign body reaction from the
deposition of the hydrophilic gel in the subcutaneous tissues during placement or removal of the sheath.
561

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kristyn M Sayball, DO
THIAZIDE DIURETICS: YOU MAY NEED A LITTLE SALT WITH THAT
Kristyn M Sayball, DO, Associate Member, Virginia Commonwealth University Health Systems
INTRODUCTION:Thiazide diuretics are one of the most common medications used in the management
of hypertension and are assumed to be relatively benign. However, they can cause significant side
effects
CASE PRESENTATION: A 66 year old female with HTN visiting family from India was brought to the ER
with several days of nausea and vomiting and the acute onset that morning of confusion, weakness, and
slurred speech. Past medical history is only significant for HTN for which she was taking Atenolol,
Chlorthalidone, and Ramipril; she had been started on Chlorthalidone approximately three months prior
to presentation after complaining of lower extremity swelling with Amlodipine. Her blood pressure
was136/80, heart rate 67, temperature 36.9C, and she was 98% on RA with a respiratory rate of 16.
Physical exam was pertinent for an alert female oriented to person only but with no other focal
neurological deficits. Lab revealed a WBC count of 22,000, a serum sodium of 99, potassium of 2.7,
chloride of 59, bicarbonate of 27, BUN of 9, and creatinine of 0.5. Her hepatic panel revealed an AST of
68 but was otherwise within normal limits. Head CT was negative for acute findings. She was admitted
to the medical ICU for management of symptomatic severe hyponatremia. Given her relatively stable
mental status despite severe electrolyte derangement she was given normal saline at 150mL/hr rather
than administering hypertonic saline. The assumption was that the drop in sodium was chronic with a
superimposed acute decrease due to gastrointestinal symptoms. Her urine electrolytes (urine sodium of
35, urine osm of 372) were consistent with diuretic induced hyponatremia. Serial repeats of these
values off diuretics over the next several days showed an expected decline in the urine sodium to < 10
and of the urine osmolality to around 250. With the above treatment the sodium level rose gradually
over the next 48 hours. Her mental status returned to baseline. Notably, discussion with the family
revealed a history of stict adherence to her low salt diet, recommended by her physician, likely
contributing to her presentaion. All other investigation into the etiology of hyponatremia was
unrevealing.
DISCUSSION: Diuretic therapy is a common cause of hyponatremia, a condition often resulting in
critical illness and at times death. Among cases of hyponatremia attributed to diuretics, thiazides are
the most common class, accounting for as many as 94%. This case illustrates the severe degree of
hyponatremia and electrolyte derangement that can result from commonly prescribed diuretics and the
importance of consistent electrolyte monitoring.
562

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kristyn M Sayball, DO
THE QUESTION TO LYSE: NOT JUST FOR THE SCHOOL NURSE
Kristyn M Sayball, DO, Associate Member, Virginia Commonwealth University Health Systems
INTRODUCTION:While there are published guidelines on the use of systemic thrombolytics in acute
clot, the decision on when to use them is not always easy.
CASE PRESENTATION: A 68 year old male presented to the emergency department complaining of
dyspnea, profound diarrhea, and weakness. He had been discharged eight days earlier after open
gastrostomy tube placement for an esophageal stricture; the procedure was complicated by a possible
liver laceration. Initial vitals on this presentation were significant for a blood pressure of 94/71, heart
rate of 126, respiratory rate of 22, and hypoxia requiring 100% oxygen via a nonrebreather mask.
Physical exam was pertinent for an elderly male in moderate respiratory distress. Cardiovascular exam
showed a regular rhythm without murmurs, lungs were clear to auscultation, abdomen was soft with
mild tenderness around the gastrostomy tube, and his extremities were cool to touch. Due to the recent
prolonged hospitalization and the above physical exam findings, we had a high suspicion for pulmonary
embolism; however, acute renal failure (serum creatinine of 1.88 mg/dL) prevented a CT angiogram. An
emergent transthoracic echocardiogram was performed which showed a 3 cm x 3 cm free floating right
atrial thrombus with right ventricular dilation and flattening of the left ventricular septum. The patient
was immediately started on a heparin drip; however, there was concern that this alone would not be
adequate. Both interventional radiology and cardiothoracic surgery were consulted for embolectomy or
thrombectomy of the atrial clot; however, given his clinical condition both consultants recommended
continued clinical management. In considering systemic thrombolytics, the team weighed the relative
contraindication of a recent open surgery with potential liver laceration. Of additional concern was the
possibility that thrombolytics would cause the thrombus to break up and migrate through the tricuspid
valve, increasing the clot burden in the lungs and further increasing afterload on an already failing right
ventricle. After a thorough review of the literature and extensive discussions with the patient regarding
the risks and benefits, the decision was made to administer thrombolytics. The patient showed
immediate improvement in both his hemodynamics and dyspnea. A bedside ultrasound later that
afternoon showed complete resolution of the right atrial thrombus.
DISCUSSION: This case presents the common problem of pulmonary embolus complicated by
additional thrombus in transit. Though rare, right atrial thrombus is associated with high
mortality. Systemic thrombolytics are associated with a high incidence of bleeding, a risk increased with
recent invasive procedures. The use of lytic therapy in this case resulted in a favorable outcome, similar
to the few reported cases in the medical literature.
563

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kenneth Surkin, MD
Severe Hyperammonemic Encephalopathy After Gastric Bypass: A Case Of The Missing Zinc.
First Author: Kenneth H Surkin, MD Second Author: Mark Flemmer, MD
Introduction : Nutritional deficiencies are a common complication of gastric bypass surgery. Rarely,
these nutritional deficiencies can lead to neurological complications and encephalopathy. Zinc
deficiency is an uncommon and often unrecognized nutrient deficiency in these patients.
Case Presentation: A 32-year-old, HIV positive, African American female presented with suicidal
ideation and altered mental status. She underwent gastric bypass surgery 1 year prior to admission. She
had extremely poor nutritional intake since the surgery and no medical follow up. After initial admission
to psychiatry for presumed major depressive disorder, her condition deteriorated and she required ICU
admission for hypotension and unresponsiveness. Initial lab-work revealed moderate transaminitis,
hypoalbuminemia, and an extremely elevated ammonia level of 422. Ultrasound of the liver revealed
only mild steatosis without evidence of cirrhosis and MRI of the brain was normal. Further lab-work
revealed profound nutritional deficiency with low levels of vitamins A, C, D, K and B6. Levels of folate
and vitamin B12 were normal. Micronutrient analysis revealed severe zinc deficiency with a level of 34
(range 70-110) and low serum copper. She was started on a regimen of lactulose, neomycin, and
rifaximin for presumed hepatic encephalopathy and oral vitamin repletion was begun. Her
cardiovascular and neurologic status improved and she was transferred from the ICU with persistently
elevated ammonia of 245. Her neurologic status deteriorated within 24 hours and her ammonia level
peaked at 683 requiring emergent hemodialysis. At this point, a diagnosis of an inborn error of
metabolism was entertained. Urine organic acid analysis revealed elevated orotic acid level of 3.18
(range 0.4-1.2). Plasma amino acid analysis showed elevated glutamine, lycine, glycine, and proline with
normal levels of carnitine and citrulline, consistent with hyperammonemia due to OTC deficiency. She
was started on IV sodium benzoate/phenylacetate to scavenge ammonia, IV zinc, and a low protein diet.
Over the next 72 hours her neurologic status improved remarkably. A direct correlation was noted
between her improved serum zinc level and the normalization of her serum ammonia. She was
discharged on a specialized diet and has recovered well. Subsequent genetic analysis did not reveal
mutations in the ornithine transcarbamylase gene, however these mutations are absent in up to 30% of
patients X-linked OTC deficiency.
Discussion: This case illustrates the dramatic neurologic complications that can result from nutritional
deficiencies following gastric bypass. While deficiency of zinc is rare, it is an essential co-factor for the
hepatic ornithine transcarbamylase (OTC) enzyme. X-linked OTC deficiency is usually asymptomatic but
in times of severe metabolic stress, such as nutritional deficiency, this disorder can be unmasked leading
to severe neurologic sequelae. With gastric bypass surgery becoming more common, clinicians should
recognize zinc deficiency as a potential cause of OTC deficiency in these patients with refractory
hyperammonemia and encephalopathy.
564

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Janki Shah, MD
ESOMEPRAZOLE-INDUCED ACUTE INSTERSTITIAL NEPHRITIS
Janki Shah, MD, Associate Christy Fagg, DO, Associate Jon Sweet, MD, FACP Ann Peters. Virginia Tech
Carilion School of Medicine, Roanoke, VA
INTRODUCTION:Acute interstitial nephritis (AIN) is an important cause of renal failure classically
associated with fevers, rash, arthralgias, eosinophiluria, eosinophilia, sterile pyuria, and white blood cell
(WBC) casts. Unfortunately, these clinical and laboratory findings have very limited diagnostic utility.
Non-steroidal anti-inflammatory drugs (NSAID), antibiotics, and certain infections have historically been
the most commonly implicated causes of AIN. However, the very frequent use of proton pump inhibitors
(PPI) seems to be an increasing cause of this problem.
CASE PRESENTATION: A 54-year-old woman developed fatigue, confusion, and anorexia over 2 weeks.
Her medical history included hypertension, depression, and heartburn. Her medications were lisinoprilhydrochlorothiazide,
citalopram, and buspirone. She was recently started on esomeprazole. She denied
recent use of NSAID or antibiotics, radiocontrast exposure, infections, or history of injuries, intravenous
drug use, transfusions, hepatitis, rash, fever, lupus, or arthralgias. There was no personal or family
history of kidney disease. Blood pressure was 146/79 mm Hg, but the rest of vital signs were normal.
She was drowsy, oriented to person and place, and had slight asterixis with a non-focal neurological
exam. The BUN was 102 mg/dL, creatinine 10.8 mg/dL, potassium 6.1 mmol/L, sodium 129 mmol/L,
phosphorus 10.0 mg/dL, WBC 12,200/mm3, and hemoglobin 12.4 g/dL. Urine was cloudy with numerous
WBC, moderate RBC, no casts or crystals, and grew >100,000 colonies/mL of Streptococcus agalactiae
Group B. The fractional excretion of sodium was 14.9% and the urine protein/creatinine ratio was 1492
mg/g. Renal ultrasonography was unremarkable. All medications were discontinued and isotonic
crystalloids were administered. Tests for the following were negative/normal: C3, C4, CH50, CK, ANA,
ANCA, ASO, anti-GBM antibody, hepatitis C, hepatitis B, HIV, urine eosinophils, and urine myoglobin. She
required dialysis for her uremic symptoms, but her renal function failed to improve. A kidney biopsy on
day 10 revealed severe AIN. Prednisone 60 mg daily was started with a prompt and sustained
improvement in her kidney function.
DISCUSSION: It is important for internists to be aware that AIN rarely presents with the classic triad of
fever, rash, and arthralgia. Our patient had none of these symptoms. She did have pyuria, but patients
with AIN would generally have sterile pyuria with WBC casts. Since the sensitivity and positive predictive
value of eosinophiluria for diagnosing acute interstitial nephritis are only approximately 25% and

VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Angela D Venuto-Ashton,
MD
FATAL RAOULTELLA PLANTICOLA PERITONITIS
Angela D Venuto-Ashton, MD Second Author: Jon Sweet, MD
INTRODUCTION: Several organisms have been reported to cause peritonitis, commonly E.Coli,
Anaerobes, Streptococci, Enterococci and Clostridia. This is the first case report citing Raoultella
Planticola as a pathogenic organism causing Acute Bacterial Peritonitis.
The following describes a case of peritonitis caused by Raoultella Planticola that was diagnosed w/ the
VITEK-2 system.
CASE PRESENTATION: A 61-year-old man with a history of hypertension and alcoholism complained of
progressing nausea, emesis and abdominal swelling for 6 months. Forty-five days before admission he
saw his physician. A comprehensive metabolic panel was normal except for an albumin of 2.6g/dL, AST
112 IU/L(10-42), and total bilirubin 7.1mg/dL. The serum urea nitrogen and creatinine were 8 and 0.9
mg/dL, respectively, and ALT was normal. Twelve days before admission he underwent an ultrasoundguided
abdominal paracentesis which yielded 6.5L of sterile, clear yellow fluid. There were 60
leukocytes/mm3, 2% of which were neutrophils. The fluid albumin and protein concentrations were
below the limit of detection.
On day of admission, he was alert, oriented, in no distress, afebrile, with a blood pressure of 108/46 mm
Hg and heart rate 104. The cardiopulmonary examinations were normal and there was obvious
ascites. The urea nitrogen and Cr were now 71 and 5.8 mg/dL, respectively, and the venous lactic acid
was 5.6 mmol/L(0.5-2.2). Sixty mL of dark turbid ascitic fluid was removed and ceftriaxone, albumin,
octreotide and midodrine were administered. The fluid contained 1,361 leukocytes/mm3, 47% of which
were neutrophils, and grew Raoultella planticola sensitive to 14 antibiotics and resistant only to
ampicillin. Blood cultures were sterile. Renal function continued to decline and intermittent
hemodialysis was started on day 5. He failed to show any improvement, a palliative approach was
adopted 3 days later, and he died soon thereafter.
DISCUSSION: The organism’s previous classification was Klebsiella subtype. Raoultella Planticola is a
rare but emerging human pathogen that correlates with infection and may prove fatal as evidenced by
this case study. Per case-reports it has infrequently been suggested as a human pathogen; which
include: Pancreatitis, soft tissue infection and most recently, a surgical site infection .
Our organism was multi-drug susceptible with the exception of Ampicillin; however reports of resistance
have been documented; including that against Carbepenems by a carbapenase gene (bla (KPC-2 and -3)
that were noted in plasmacidic and chromosomal locations. Additionally there have been reports of
Beta lactamase resistance.
Although the organism was readily identified and treated appropriately even before final-culture
returned it still proved fatal. R. Planticola is an uncommon but nonetheless important pathogen when
considering antibiotic care and treatment of atypical pathogens in peritonitis.
566

WASHINGTON POSTER FINALIST - CLINICAL VIGNETTE Julie B Silverman, MD
Lambert Eaton: An Elusive Diagnosis
Julie Silverman, MD, Associate; Susan Merel, MD
INTRODUCTION:Lambert Eaton myasthenic syndrome (LEMS) is an uncommon disorder of the
neuromuscular junction. Although the symptoms are well-described, the diagnosis of LEMS can be
difficult due to the non-specificity of symptoms and to the rarity of the disease. Because of its high
association with malignancy, LEMS is important to consider in older patients presenting with weakness
and autonomic dysfunction.
CASE PRESENTATION: A 70-year-old previously healthy woman presented to her primary care
physician (PCP) with concerns of dyspnea, orthopnea and peripheral edema. Review of systems further
revealed malaise, fatigue, muscle weakness, nausea and excessive thirst. Patient underwent extensive
cardiopulmonary workup including unremarkable ECG, TTE, myocardial scintigraphy study, chest CT scan
and pulmonary function tests. Patient's symptoms continued, with worsening dry mouth, anorexia and
unintentional fifteen-pound weight loss over the next two months. An EGD, colonoscopy, abdominal
ultrasound and abdominal CT scan were obtained, all of which were unrevealing. Concerned that
depression might be the cause of the patient's symptoms, patient's PCP started her on a selective
serotonin reuptake inhibitor (SSRI). Patient denied improvement in symptoms with SSRI. Patient was
ultimately admitted to the University of Washington with severe hyponatremia (Na 112 mEq/L), due to
hypovolemia and SSRI-induced SIADH. Despite normalization of sodium, patient’s symptoms of
weakness, malaise and autonomic dysfunction continued, prompting further investigation. An
electromyogram (EMG) with repetitive stimulation was performed, which showed a disorder of
presynaptic neurotransmission consistent with LEMS. Patient underwent extensive malignancy workup
– including CT chest, abdomen, pelvis, PET scan and serum tumor markers – which returned negative.
She was started on pyridostigmine and 3,4-DAP with subjective improvement in symptoms within days
of starting treatment. At time of diagnosis, which was six months after initial presentation to PCP,
patient had been hospitalized at five different institutions, undergone more than a dozen studies and
procedures and had been evaluated by at least six different subspecialty services.
DISCUSSION: This case illustrates the potential difficulty of diagnosing LEMS. While the prevalence is
low, recognition of this syndrome is critical, as sixty percent of patients with LEMS have an underlying
malignancy, and treatment can be quite effective in reducing symptoms.
567

WASHINGTON POSTER FINALIST - CLINICAL VIGNETTE Sarah Anne Buckley,
MD
Pernicious Anemia Mimicking Acute Erythroblastic Leukemia
Sarah Buckley, MD; Pamela Becker, MD
INTRODUCTION: Vitamin B12 deficiency causes characteristic hematologic alterations such as
increased MCV, hypersegmented neutrophils, hemolysis, and cytopenias. These resolve with
replacement of vitamin B12. The following case describes a patient with pernicious anemia whose
vitamin B12 deficiency was so severe that he developed hematologic abnormalities initially concerning
for acute erythroblastic leukemia or myelodysplastic syndrome. These abnormalities, including the
presence of peripheral blasts and severe marrow dyserethropoeisis, corrected with vitamin B12
administration.
CASE PRESENTATION: A 26-year-old previously healthy African American man presented to the
hospital with a one-month history of fatigue and a witnessed syncopal episode. On presentation, the
patient was alert with normal vital signs. A non-contrast head CT ruled out any acute intracranial
process. Laboratory studies revealed a white blood cell count of 2400 cells/mm2 with a lymphocytic
predominance, a hemoglobin of 5.6 g/dl with an MCV of 107 fl and a reticulocyte index of 0.2%, a
platelet count of 125,000 cells/ul, a haptoglobin 4000 U/L, an undetectable level
of vitamin B12 (

WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Abdel Rahman M
Lataifeh, MD
bath Salts Are Dope Not Soap
Authors: Lataifeh,A.MD Alourani,M. MD Zeid, F. MD,FCCP
INTRODUCTION: In the time period between January to September of 2011, about 239 cases of bath
salt intoxication were reported to the poisoning center of West Virginia. This drug has been nicknamed
bath salts, but you don't actually use them in your bathtub. In fact, they're a type of designer drug used
to get high. The main active components are mephedrone and methylenedioxypyrovalerone (MDPV).
Pharmacologically, they function as a dopamine-norepinephrine reuptake inhibitor (NDRI) with
stimulatory effects on the central nervous system and cardiovascular system. Clinical manifestations
include adrenergic crises, hallucinations, seizures, rhabdomyolysis, nephrotoxicity and hepatotoxicity.
This case series will present three patients that were admitted to the ICU after bath salts intoxication.
CASE PRESENTATION:
Case # 1:
43 year-old male, admitted with decreased level of consciousness which required mechanical
ventilation. On admission he had hypertension with tachycardia. Blood pressures (BP) as high as
190/110 were recorded. His laboratory work showed hypoglycemia, acute renal failure, disseminated
intravascular coagulopathy (DIC), rhabdomyolysis, lactic acidosis and hepatic injury. He was supported
with intravenous fluids, benzodiazepines, bicarbonate, fresh frozen plasma, and platelet transfusions.
He also needed hemodialysis and was discharged home after 12 days.
Case # 2
50 year-old male, brought to the emergency department (ED) with altered mental status after injecting
himself bath salts intravenously. He reported that he had been using it for 2 days “at low doses.” His BP
was normal on admission but on the second day it rose to 170/110. His work-up showed acute nonoliguric
renal failure and mild elevation of his creatine kinase (CK). His liver enzymes were normal and he
was discharged home after 3 days with normal kidney function tests and CK levels.
Case # 3
30 year-old male, admitted with decreased level of consciousness and aspiration. His 20 -day
hospitalization in the ICU was complicated by lactic acidosis, rhabdomyolysis, hypertension, oliguric
renal failure, and hepatotoxicity. He was supported with mechanical ventilation, sedation, fluids,
bicarbonate, and hemodialysis.
DISCUSSION: Patients presenting to the ED with adrenergic crises, altered mentation, rhabdomyolysis,
lactic acidosis, hepatotoxicity or nephrotoxicity should be evaluated carefully for possible bath salts
intoxication, even if the routine urine drug screens were negative. This case series represented how
variable the severity and duration of bath salts intoxication syndrome can be. Of note, the DIC and
hypoglycemia in the first case were unusual manifestations that have not been reported in prior case
reports. The redeeming news is that as of October 21, 2011, the drug enforcement authority (DEA)
announced “MDPV, its salts, isomers and salts of isomers have been temporarily controlled in schedule I
of the controlled substances act.”
569

WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Dheeraj Kodali, MD
There is a reason they call it 'Super'-Warfarin!
Dheeraj Kodali, MD Author: Jack DePriest, MD
INTRODUCTION:Rodenticide (“super-warfarin”) poisonings are a significant public health concern. Over
11,000 cases were reported in 2009, including 337 self-poisonings. Sold commercially as D-con®,
Brodifacoum, a vitamin K antagonist, is 100 times more potent than its parent compound coumarin and
has a half-life ranging from weeks to months. While the management of superwarfarin ingestions
mirrors that of warfarin associated bleeding (high dose Vitamin K with clotting factors as clinically
indicated), this remarkable case highlights that the doses of Vitamin K required can greatly exceed what
most internists might consider “high dose”.
CASE PRESENTATION: An eighteen year-old Caucasian female with a history of previous suicide
attempts presented with abdominal distension, left flank pain and bruising of 4 days
duration. Abdominal imaging revealed hemoperitonium and a left adnexal mass. Serum Beta HCG was
positive. Admission lab investigations revealed an APTT of 106. The PT/INR report indicated “no
coagulation observed in reaction tube”. The patient received Vitamin K and Fresh Frozen Plasma (FFP)
and her INR briefly corrected to 1.6. Later on the day of admission, the patient admitted to having
consumed brodifacoum every day for almost three weeks. Three days prior to admission she stated she
consumed approximately 20 bars.
On the morning of the 3 rd ICU day, her PT/INR was 14.8/1.4, having received 40 mg of Vitamin K, 16
units of FFP and 3 doses of Prothrombin Complex Concentrate (PCC) since admission. Over the course
of that day and evening her INR started to climb again despite now receiving 10 mg of Vitamin K IV every
6 hours and 2 additional doses of PCC. Her PT/INR peaked at >120/ > 11 the next morning, day 7 post
consumption. The patient was given a 20 mg bolus of Vitamin K IV and started on a continuous infusion
at 10 mg per hour. Her next INR 3 hours into the continuous infusion was 1.46. The INR stayed below
1.3 while on the continuous infusion. The infusion was stopped after 24 hours and the patient was
started on 20 mg of Vitamin K PO every 4 hours. Even after 510 mg of vitamin K over 5 days, her INR
climbed from 1.09 to 2.55 over the next 4 days.
DISCUSSION: Super-warfarin poisonings may present therapeutic challenges far greater than seen with
warfarin associated bleeding. This case illustrates that high dose Vitamin K remains the cornerstone of
managing super-warfarin ingestions. Most importantly, it illustrates that what most internists might
consider high doses of Vitamin K may not come close to being adequate in the setting of a significant
ingestion. The clinical time-line (time to peak effect, required duration of therapy) is also very different
with this ingestion.
570

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Deepa R Ovian, MBBS
Chapter Winning Abstract Curse of the Caribbean
Deepa R. Ovian, MBBS William A. Agger, MD
INTRODUCTION:Mycotic aneurysm is a rare but serious complication of non-typhoidal salmonella
bacteremia, occuring most commonly in the abdominal aorta. The clinical presentation is nonspecific
and a high index of suspicion is necessary to make an early diagnosis as mortality is high without
timely intervention.
CASE PRESENTATION: A 74 year old lady with rheumatoid arthritis treated with hydroxychloroquine,
developed 1 episode of mild gastroenteritis of 1 -2 days duration while on a week long vacation in the
Caribbean.
6 weeks later, she was admitted to a local hospital with gradual worsening of her chronic back pain,
generalized weakness, frequent falls and episodes of confusion. She was afebrile with stable vitals and
had marked back pain with movement. Palpation tenderness was present in the paraspinal region of her
lower back. CT head and x-ray of lumbar spine was unrevealing. Blood cultures grew Salmonella
serotype enteritidis. The patient received IV levofloxacin for 5 days and with clinical improvement, she
was discharged with an additional 5 days of oral levofloxacin.
3 weeks later, the patient was readmitted to the same hospital with complaints of persisting back pain,
weakness and confusion. She had a fever of 104.2F with midline lumbar tenderness. After transfer to
our hospital for further care, we performed an MRI of the spine which showed L4- L5 diskitis. Blood
cultures and disc space aspirate cultures grew S. enteritidis. As recommended by our ID consultant, we
also investigated for an endovascular infection with a CT abdomen, which showed a 2 cm saccular
mycotic aneurysm of the distal abdominal aorta. While on ceftriaxone, patient underwent
aneurysmectomy with aortic reconstruction using autologous spiral saphenous vein graft. Tissue culture
from the resected aneurysm also grew S. enteritidis. She was continued on ceftriaxone for a total of 6
weeks. Her pain improved and she was doing well when seen 2 months later at follow-up in clinic .
DISCUSSION: This case demonstrates the importance of clinicians' awareness that adults with a relapse
of non- typhoidal salmonella sepsis often have a serious endovascular infection. This risk is increased in
patients above 50 years of age with atherosclerosis. In such patients, it is important to look for a
vascular infection even if a focus of infection has been identified elsewhere. Anti-salmonella
antimicrobial therapy should be started and a CT or MRI with contrast should be performed on an
emergency basis. Following diagnosis, surgical resection of the aneurysm with in situ graft
revascularization, the procedure of choice, should be done as soon as possible. Postoperative
antimicrobial therapy for 6-8 weeks based on ESR and clinical response is recommended.
571

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Asma Arayan, MD
Renal ischemic preconditioning: that which does not kill us makes us stronger
Asma Arayan, MD; Second Author: Balaji Srinivasan, MD
INTRODUCTION: In the setting of ischemic injury to an organ, it might be expected that the organ
would be more susceptible to a second ischemic insult. Considerable data however exists, that there are
intrinsic mechanisms that actually protect the organ against subsequent ischemia. This concept referred
to as ischemic preconditioning is an innate tissue adaptation induced by ischemia or toxic insult that
confers organ protection against subsequent exposure to the same or other injury.
CASE PRESENTATION: We recently had two patients with acute kidney injury who were exposed to a
second nephrotoxic insult. They did not have a significant increase in their serum creatinine or decrease
in urine output after the second insult. The first patient was a 55-year old woman with history of
diabetes with microalbuminuria. She presented with AKI likely due to acute tubular necrosis from
volume depletion following a diarrheal illness. As she had multiple risk factors for contrast nephropathy
including diabetes, elevated serum creatinine and volume depletion, the plan was to do a computed
tomography (CT) of the abdomen without intravenous iodinated contrast. However, intravenous
contrast was inadvertently administered. Although she was exposed to a second nephrotoxic insult, she
did not develop contrast nephropathy. Her urine output improved overnight and her creatinine was
back to normal over the next few days. The second patient was a 73-year old male admitted with AKI
due to rhabdomyolysis. He required one hemodialysis treatment. Over the next 3-4 days his creatinine
returned to baseline. By hospital day 6, he developed worsening hypoxemia and he was suspected to
have pulmonary embolism. He was given IV iodinated contrast for a chest CT. He had good urine output
and his serum creatinine was stable over the next few days. Despite being exposed to a second
nephrotoxic insult within a week, he did not develop contrast nephropathy.
DISCUSSION: Ischemic preconditioning was first described in the heart. Episodes of ischemia in canine
myocardium, followed by reperfusion protected against myocardial necrosis during a subsequent
prolonged period of ischemia. Patients with pre-infarction angina have smaller infarct size when
compared to patients with acute myocardial infarction without preceding angina. Animal studies have
shown that a similar phenomenon occurs in the kidneys. Renal tubular epithelium in these studies has
been shown to be resistant to a second nephrotoxic insult after initial injury. Ischemic preconditioning
can be local or remote. Human studies have shown that remote ischemic preconditioning prevents
acute kidney injury in patients undergoing cardiopulmonary bypass-assisted cardiac surgery.
Biochemical pathways involved in ischemic preconditioning have recently been elucidated. Our cases
suggest that local renal ischemic preconditioning could occur in humans.
572

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Tessa W Damm, DO
A Non-Compact Diagnosis
Tessa W Damm, DO Second Author: Kurt Pfeifer, MD, FACP
INTRODUCTION: Left ventricular non-compaction is a rare cause of congenital cardiomyopathy worthy
of proper diagnosis as these patients are at increased risk of arrhythmic events as well as
thromobembolic complications.
CASE PRESENTATION: A 30-year-old gentleman presented with a four-week history of non-productive
cough and dyspnea on exertion. His past medical history was unremarkable except for a seven pack-year
smoking history. Twice previously he had been evaluated for the same symptoms and received
antibiotics and short-acting bronchodilator therapy for treatment of an upper respiratory tract infection.
With these therapies he had only transient relief of his symptoms. On his third presentation, physical
examination revealed an S3 cardiac gallop and a laterally displaced point of maximal
impulse. Concurrent chest radiograph was notable for cardiomegaly and evidence of cardiopulmonary
vascular congestion. Chest CT was unremarkable for pulmonary embolus. Echocardiography revealed
globally decreased left ventricular systolic function with an estimated ejection fraction of 10–20%. The
echocardiogram was also notable for a thickened appearance to the left ventricular wall. This finding
prompted further evaluation with cardiac MRI which revealed a ratio of trabeculated to compacted
myocardium on the lateral wall of the left ventricle of greater than 2:1, confirming cardiomyopathy of
non-compaction etiology. The patient was started on optimal medical management for heart failure
including a beta-blocker, angiotensin converting enzyme inhibitor, and spironolactone. He was also
started on anticoagulation as the risk of thromboembolic complications in patients with non-compaction
cardiomyopathy is increased. Repeat echocardiogram approximately three months after initiation of
optimal medical management did not reveal improvement in left ventricular systolic function; therefore,
the patient is currently undergoing evaluation for placement of an automatic implantable cardioverterdefibrillator
as well potential future heart transplantation.
DISCUSSION: Non-compaction cardiomyopathy is an uncommon etiology of heart failure with an
estimated prevalence of 0.05-0.24%. Age of initial presentation varies widely and males are more
commonly affected than females. It is believed that the disorder is secondary to an arrest of normal
compaction of a loose meshwork of trabeculae which constitute the myocardium between the fifth and
eighth week of embryonic development. In addition to systolic dysfunction, this population of
individuals is at unique risk for arrhythmias and thromboemolic events. Aggressive medical management
with heart failure pharmacotherapy and defibrillator placement is the mainstay of treatment. If these
measures fail, many patients with non-compaction cardiomyopathy are candidates for heart
transplantation given their relative young age and lack of comorbid conditions. Furthermore, first
degree relatives of these patients should be considered for clinical screening due to the disease’s
identifiable genetic associations.
573

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Zouyan Lu, MD
Syphilis-related immune reconstitution inflamatory syndrome
Zouyan Lu, MD Second Author: J. Njeri Wainaina, MD
INTRODUCTION: Morbidly and mortality associated with human immunodeficiency virus (HIV)
infection has improved greatly with the advent of highly active antiretroviral therapy
(HAART). However, rapid restoration of the host immune system may sometimes lead to a pathologic
host immune response.
CASE PRESENTATION: A 45 year-old male with AIDS presented with acute onset aphasia approsimately
one year after self-discontinuing his HAART. CT of the head showed acute ischemic stroke and cerebral
vascular pathology. Cerebrospinal fluid (CSF) analysis was consistent with meningitis; serum free
treponemal antibody was reactive. He was treated for meningovascular syphilis with 2 weeks of
intravenous penicillin and restarted on his previous HAART of efavirenz and lamivudine/zidovudine. He
returned a day after completing treatment with complaints of fever, neck pain and acute onset
headache. CT scan showed intraventricular hemorrhage, new right parietal infarcts and findings
consistent with vasculitis. He was started on empiric treatment with IV vancomycin, ceftriaxone, and
acyclovir. Within 24 hours of admission, he had acute neurological decline, repeat imaging showed new
infarcts. CSF was significant for elevated red blood cell count, a low glucose and neutrophilic
pleocytosis. Gram stain and culture were negative. CSF cryptococcal antigen, HSV PCR, and VDRL were
also negative. His HIV viral load, when compared to values obtained 3 weeks prior, showed a 3 log
decrease. Brain MRI showing more new infarcts and leptominingeal enhancement, in conjunction with
the rapid decline in viral load, led to concern for IRIS. Empiric antibiotics were stopped and high-dose
steroids were started with initial response. But the patient later developed step-wise decline in
neurologic status steroids were tapered down. The patient eventually became minimally responsive
with extensor posturing. After discussion with his family, he was transferred to home hospice.
DISCUSSION: IRIS often presents with a paradoxical decline caused by a pathologic response of the
host’s reconstituted immune system after initiation of HAART. Some investigators have reported an
incidence as high as 23% in patients starting HAART. The risk for developing IRIS appears to be directly
proportional to opportunistic infection disease burden. IRIS should be suspected when patients present
with unusual symptoms or disease course with a temporal relation to immunological recovery following
initiation of HAART. It is most commonly described in association with mycobacterial, fungal, and viral
infections. While, any organ system can be involved, reports of CNS IRIS are less common. There are no
published trials for the treatment of IRIS, but case studies suggest appropriate treatment of the
underlying opportunistic infection with or without the addition of corticosteroids. Our patient had
progression of CNS vasculitis associated with a rapid and robust immune recovery following initiation of
HAART. The only opportunistic infection identified was meningovascular syphilis for which he had been
appropriately treated. He demonstrated clinical neurological improvement with initiation of steroids
and catastrophic decline when tapering was attempted.
574

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Christiane N Mbianda, MD
An Incidental Aortic Ulcer:Hickam's dictum Vs Occam's razor
Christiane Mbianda,Jennifer Yacub,Peter-Trung Phan, Siddharta Singh,Medical College of
Wisconsin,Milwaukee,WI
INTRODUCTION: A 73-year- old male was hospitalized for evaluation of a four-week history of diarrhea.
Initial evaluation revealed leukocytosis (WBC = 16,000/µl); elevated inflammatory markers (ESR =
88mm/Hr). Abdominal CT showed colonic thickening around the hepatic flexure. A colonoscopy revealed
an ulcerating, necrotic mass in the cecum, confirmed to be an adenocarcinoma on pathological exam.
The patient had an episode of atrial flutter and underwent a contrast enhanced chest CT for suspected
pulmonary embolism (PE). Chest CT showed no PE but incidentally revealed an aortic ulcer in the distal
aortic arch. A PET scan showed no metastatic disease, but marked uptake in the region of the aortic
ulcer, suggesting inflammation. A literature search revealed an association between infectious aortitis
and colon cancer but blood cultures drawn on admission remained negative, and the patient remained
afebrile. Subsequently, he was noted to have a hoarse voice, which prompted repeat imaging that
revealed marked progression of the aortic ulcer and a 3.3 cm pseudo aneurysm. The patient underwent
emergent surgery and the resected necrotic aortic arch grew Clostridium septicum. He initially made a
remarkable recovery, but 3 days prior to the planned resection of his colon cancer - he suffered a
cardiac arrest and died.
DISCUSSION: This case is notable for two reasons. Firstly, Clostridium septicum is an uncommon cause
of aortitis and has a striking association with colon cancer. To the best of our knowledge, we are
reporting the 27 th case of C. septicum aortitis and the 21 st case associated with colon cancer.
Secondly, the diagnostic journey in our case is intriguing. The incidental discovery of an aortic ulcer in a
patient with newly diagnosed colon cancer set into play an age old conflict between Occam’s razor and
Hickam’s dictum. Occam’s razor, which states “plurality must not be posited without necessity” is the
classic heuristic of medical diagnosticians but with our aging patient population suffering an epidemic of
chronic diseases, Hickam’s dictum, which states - “a patient can have as many diagnoses as he darn well
pleases” is holding true more often. In our case, as blood cultures were negative and the patient
remained afebrile, Hickam’s dictum dominated initially–prompting the hypothesis of an atherosclerotic
aortic ulcer and an unrelated diagnosis of colon cancer. This changed with the development of
hoarseness–which signaled the progression of the aortic arch pathology. This prompted repeat imaging,
surgery and subsequent pathological exam which revealed a parsimonious explanation for the patient’s
clinical conditions and the ultimate triumph of Occam’s razor: Proliferation of C. septicum in the
anaerobic, necrotic areas of the colon cancer with eventual occult C. septicum bacteremia and resulting
aortitis.
575

WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Jessica L White, MD
Cellulitis As A Symptom, Not A Diagnosis
Jessica L White, MD
INTRODUCTION: Skin and soft tissue infections require a broad differential diagnosis especially when
presenting with frequent recurrence despite appropriate treatment. Further investigation can help
diagnose other underlying disease processes that should be considered in atypical cellulitis.
CASE PRESENTATION: A 64 year-old woman with a past medical history of hypertension and eczema
presented with recurrent lower extremity pain and erythema. She had a history of several episodes of
cellulitis that improved with antibiotics but recurred shortly after completing therapy. She was treated
with multiple courses of antibiotics over a period of 4 months. Physical examination during this
presentation demonstrated bilateral inguinal lymphadenopathy, multiple hypopigmented skin patches
and diffuse papular rash with lichenification and crusting on the torso, upper and lower extremities.
Initial laboratory evaluation was significant for leukocytosis and elevated liver function tests. Chest,
abdomen and pelvis CT showed diffuse bilateral lymphadenopathy as well as multiple small pulmonary
nodules. Subsequent lymph node and skin biopsies confirmed a diagnosis of CD30+ peripheral T cell
lymphoma not otherwise specified (PTCL NOS). She underwent 6 cycles of cyclophosphamide,
hydroxydaunorubicin, vincristine and prednisone (CHOP), and 3 cycles of etoposide,
methylprednisolone, cytarabine and carboplatin (modified ESHAP). Despite these therapies, she had
recurrence of her lymphoma and died 9 months after diagnosis.
DISCUSSION: Peripheral T-cell lymphomas account for approximately 12 percent of all adult non-
Hodgkin lymphomas with PTCL NOS being the most common subset at 30 percent. Approximately half
the cases of PTCL NOS include extranodal involvement, and cutaneous findings are a common
presentation. Our patient presented with recurrent cellulitis of her lower extremities which did not
adequately respond to appropriate antibiotic therapy. Our review of the literature found only two
abstracts citing similar cases of PTCL presenting as recurrent cellulitis. Diagnosis requires tissue biopsy
of either involved skin or lymph nodes. Treatment of PTCL NOS involves combination chemotherapy
with CHOP being the most commonly used therapy. This neoplasm has a poor prognosis due to an
aggressive course with high chance of relapse, and survival is associated with disease stage at the time
of diagnosis. One study cited 82 PTCL NOS patients with cutaneous findings had an overall unfavorable
prognosis with a 20% five-year survival. Maintaining a high index of clinical suspicion in a patient with
atypical skin findings such as recurrent infection can help lead to earlier diagnosis and treatment.
576