J-LSMS 2021 | Winter

J-LSMS 2021 | Winter

JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 173 | ISSUE 3 | WINTER 2021

D. LUKE GLANCY, M.D. EDITOR, JOURNAL OF THE LSMS 2001 TO 2021 THE OF Legacy RETIRING

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VOL 173 | ISSUE 3 | WINTER 2021 CONTENTS

JOURNAL EDITORIAL STAFF

EDITOR D. Luke Glancy, MD

ASSOCIATE EDITOR L.W. Johnson, MD

CHIEF EXECUTIVE OFFICER JeffWilliams

4 MESSAGE FROM THE EDITOR 4 LSMS…THE VOICE OF LOUISIANA PHYSICIAN 5 DONNA BREEN INSTALLED AS SMA PRESIDENT 6 THE LEGACY OF D. LUKE GLANCY, MD 8 VACCINE MANDATE 9 THESE MEMBERS HAVE BEEN PHYSICIANS FOR 50 YEARS 11 INMEMORIAM THESE PHYSICIANMEMBERS PASSED AWAY IN 2021 10 LOUISIANA STATE BOARD OF MEDICAL EXAMINERS 12 VALIDATE YOUR INFORMATION WITH MEDICAID EARLY 13 MEDICAID ENROLLMENT DRIVE CALENDAR 14 LSMS MEMBERS APPOINTED TO LOUISIANA PATIENTS COMPENSATION FUND (PCF) OVERSIGHT BOARD 14 MEDICAL REVIEWPANELS GROSS NEGLIGENCE STANDARD OF CARE 14 CLASSIFIEDS 16 ABSTRACTS FROM THE LOUSIANA ACP WITH WINNERS AT ANNUAL MEETING MARCH 2021-2-2 16 NOT THE EXPECTED DIPLOCOCCI: A RARE CASE OF GONOCOCCAL INFECTIVE ENDOCARDITIS 17 RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB 18 ACUTE ONSET OF HOARSENESS OF VOICE IN A MIDDLE AGED MALE PATIENT

JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD

Anthony Blalock, MD D. Luke Glancy, MD L.W. Johnson, MD Fred A. Lopez, MD

LSMS 2021 BOARD OF GOVERNORS OFFICERS President, William Freeman, MD Past President, Katherine Williams, MD President-Elect, John Noble, Jr., MD Vice President, George Ellis, Jr., MD Speaker of the House, T. Steen Trawick, MD Vice Speaker, R. Reece Newsome, MD Secretary/Treasurer, Richard Paddock, MD Chair, COL, David Broussard, MD COUNCILORS District 1 Member, Myra Kleinpeter, MD District 1 Alternate, Maurice Sholas, MD District 2 Member, Robert Chugden, MD District 3 Member, Allen Vander, MD District 4 Member, Richard “Rick”Michael, MD District 5 Member, Gwenn Jackson, MD District 6 Member, Michael Roppolo, MD District 7 Member, Brian Gamborg, MD District 8 Member, Lance Templeton, MD District 9 Member, Andy Blalock, MD District 10 Member, Nicholas Viviano, MD District 10 Alternate, James Connolly, MD SECTION REPRESENTATIVES Senior Physician Member, Marcus Pittman, III, MD Senior Physician Alternate, Donnie Batie, MD Young Physician Member, Amberly Nunez, MD Resident/Fellow Member, Blake Denley, MD Medical Student Member, Brittany Wagner Employed Physician Member, Matthew Giglia, MD Private Practice Physician Member, Vicki Steen, MD

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MESSAGE FROM THE EDITOR

As we continue to battle the COVID Pandemic, I send my heartfelt sympathies to all who have lost their family members and friends to COVID. I would also like to commend all healthcare providers who have worked tirelessly and put themselves in harm’s way to care for COVID patients around the state. I have had the honor and privilege of serving as Editor-in-Chief to the LSMS Journal since January 1, 2002. Alas, it is time for me to resign this post as of January 1, 2022. I am forever grateful for the many great physicians of our state who served on the journal’s editorial board with me over these many years. I would also like to thank Jeff Williams and all of the LSMS staff who have been kind, considerate and competent in helpingme make the LSMS Journal a valuable asset to Louisiana physicians.

Last but not least, I would you like to thank my wife Cynthia for her unwavering love and support throughout the years. ■

D. Luke Glancy, MD Editor-in-Chief

LSMS…THE VOICE OF LOUISIANA PHYSICIANS

When you join the Louisiana State Medical Society (LSMS), we support your interests and the issues that matter to you. We provide an outlet for your voice as a profession, in our case physicians, to be heard. What does it mean to have the LSMS on your side? It means

polices and positions approved or implemented by the AMA. Historically, these differences were all related to the practice of medicine and to physicians. However, in recent years the AMA has gotten further away from medicine as its wading into social justice and political waters that have nothing to do with medicine. Furthermore, many of these differences are in stark contrast to our policies (LSMS), customs, and beliefs here in Louisiana. As such, I feel its necessary today to make sure every Louisiana physician knows and understands that the Louisiana State Medical Society (LSMS) has no formal affiliation with, authority over, nor do we sponsor or endorse the opinions of, or information disseminated by, the American Medical Association (AMA). The LSMS represents the physicians of Louisiana, their values and beliefs and are bound by polices approved by our House of Delegates and Board of Governors. ■

you have an organization that will listen, investigate issues, andmake your voice, the physicians voice, heard. However, at times, that message may be confused with what others are doing or saying. In my sixteen years at the LSMS, I’ve found our organization at odds with the American Medical Association (AMA) many times over differing views. In fact, as an organization, the LSMS spends time each year distancing Louisiana from irresponsible and unnecessary

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DONNA BREEN INSTALLED AS SMA PRESIDENT

Advocacy, Leadership, Quality and Professional Identity

Donna Breen, MD, LSMS since member since 1991, was sworn in as the 115th President of the Southern Medical Association on October 30, 2021. Dr. Donna Breen of Marksville, LA is a cum laude graduate of UniversityofAlabamaMedical School andtrained ingeneral surgery and completed her residency in Otolaryngology at

Tulane University Medical Center in New Orleans. She is board certified in Otolaryngology, Head and Neck Surgery and completed a fellowship in Otolaryngic Allergy. Founded in 1906, the Southern Medical Association is a scientific body of physicians dedicated to fostering the art and science of medicine through education. ■

1 Southern Medical Association Alliance President, Karen Pastora and Donna Breen, MD 2 Dr. Breen (right) being congratulated by LSMS Alliance members Rose Kuplesky (left) and Emma Borders (center). 3 Donna Breen, MD being sworn in as the 115th President of the Southern Medical Association by outgoing president Christopher Morris, MD.

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2

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J LA MED SOC | VOL 173 | WINTER 2021

OF Legacy

THE

D. Luke Glancy, MD

David Lucas (Luke) Glancy was born in Cincinnati, Ohio and reared in Atlanta, Georgia. He receivedhisMDdegree fromThe Johns Hopkins and completed a residency in Internal Medicine at The Johns Hopkins Hospital and Atlanta’s Grady Memorial

Dr. Glancy joined the American Heart Association in 1966 and has been a fellow of its Council on Clinical Cardiology since 1970, twice serving as the Council’s Mississippi/ Louisiana representative. He served the Louisiana Affiliate of the AHA in many capacities, was its president in 1982- 83, and its Heart Gala honoree in 2001. Dr. Glancy also is a fellow of the American College of Physicians and of the American College of Cardiology. He was named a Master Teacher of the American College of Cardiology in 1973 and was Governor of the Louisiana Chapter of the ACC from 1982 to 1985. He is a fellow of The Society for Cardiac Angiography and Interventions, which he helped found in 1978, and a member of the Southeastern Clinical Club the Southern Society for Clinical Investigation, the American Federation for Clinical Research, and the New Orleans Academy of Internal Medicine. He has 300 publications in peer-review medical journals. Dr. Glancy joined the Louisiana State Medical Society in 1974 and was inducted into the Society’s Hall of Fame in 2020. Glancy has been the Editor for the Journal of the LSMS since January 1, 2002 and has presided over the publication of more than 100 issues during his 20 years as editor.

Hospital where he served as Chief Resident. Dr. Glancy served in the United States Public Health Service from 1966 to 1972 and was assigned to the National Heart Institute in Bethesda, Maryland where he worked in cardiac pathology for two years and was Chief of Cardiovascular Diagnosis his last four years. In 1972 Dr. Glancy began working for the LSU Medical School in New Orleans as Chief of Cardiology. In 1974, he became Medical Director of Cardiology at Hotel Dieu (now University Hospital), a position he held for 18 years. He returned to academic medicine in 1992 as Chief of Cardiology both at LSU and at University Hospital. Since his retirement on April 1, 2014, he serves as Emeritus Professor of Medicine, Emeritus Director of the Cardiology Fellowship Training Program, Emeritus Chief of Cardiology at LSU.

300 publications in peer- reviewmedical journals

1966 to 1972

1966

1970

1972

1973

Served in the United States Public Health Service

Joined the American Heart Association

AHA Fellow of Council on Clinical Cardiology since

Chief of Cardiology, LSU Medical School in New Orleans

Master Teacher of the American College of Cardiology

1982 to 1985

1982-83

1978

1974

1974

ACC Governor of Louisiana Chapter

AHA president

Found The Society for Cardiac Angiography and Interventions

Joined the Louisiana State Medical Society

Medical Director of Cardiology at Hotel Dieu

2020

1992

2001

2002

2014

inducted into the Society’s Hall of Fame

Chief of Cardiology both at LSU and at University Hospital

AHA Gala honoree

Begins serving as Editor of the Journal of the LSMS

Emeritus Professor of Medicine, Emeritus Director of the Cardiology Fellowship Training Program, Emeritus Chief of Cardiology at LSU

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Luke will be missed “ “ “

Dr. Glancy has been a steady hand at the wheel when the Journal and the Society needed it most. His leadership and foresight were essential to the success of the Journal and the longevity of the society. He will be sorely missed.” - Andy Blalock, M.D., Journal Board Member

No one could have surpassed the effectiveness of Dr. Glancy in navigating the challenges of multiple literal and figurative storms for our state and journal. He has been steadfast in the mission of the journal to improve outcomes for our members and patients. It has been an honor and pleasure to work with such a gentleman and scholar.” - Lester W. Johnson, M.D., Associate Editor Thoughtful, dedicated, collegial, articulate, meticulous and professional—these are but a few of the words that come to mind when I think of Dr. Luke Glancy. He was initially my teacher and inspiration for medicine, a true master of the physical exam and the consummate cardiologist. Later in my career, Luke became a mentor and model for the importance of taking on responsibilities that complemented his passion to teach and disseminate knowledge through other venues. A primary medium for this expression has been the Journal of the Louisiana State Medical Society, over which he has presided as editor for two decades. Under his leadership, the journal has remained a consistent vanguard of the medical community in Louisiana and beyond. His thoughtful editorials, his attention to the quality of journal submissions, and the use of his considerable interpersonal skills to encourage article reviews have allowed the journal to serve as a proud “ambassador” for the state medical society. No doubt, his remarkable talents and extraordinary commitment to the journal will be missed, but his legacy as editor, without peril, will endure.” - Fred Lopez, M.D. Dr. Glancy’s hard work, dedication and achievements to the Journal of the LSMS may never be matched. After twenty years of excellent service, he leaves behind a legacy of hard work and commitment. Thank you for always supporting our team with your constant positivity and encouragement. We will miss you!” - Jeff Williams, LSMS Executive Vice President & CEO ■

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VACCINE MANDATE On Tuesday, November 16, 2021, Louisiana Attorney General, Jeff Landry filed a lawsuit challenging the legality of the Centers for Medicare and Medicaid Services’ rule mandating COVID vaccines for nearly every full-time employee of healthcare facilities receiving Medicaid or Medicaid funding. Landry asserts that the mandate will upend the state budget and create healthcare shortages. The complaint was filed in federal court in Louisiana by a 12-state coalition including Montana, Alabama, Arizona, Georgia, Idaho, Indiana, Louisiana, Mississippi, Oklahoma, South Carolina, Utah, and West Virginia. November 30th the United States District Court for the Western District of Louisiana issued a preliminary injunction against the implementation and enforcement of the vaccine mandate against Medicare and Medicaid- certified providers. This order covers all states, the District of Columbia and the US Territories. Per the memo issued by CMS on December 2nd, it will not enforce the

new rule regarding vaccination of health care workers or requirements for policies and procedures in certified Medicare/Medicaid providers and suppliers (including nursing facilities, hospitals, dialysis facilities and all other provider types covered by the rule) while there are court- ordered injunctions in place prohibiting enforcement of such. ■

To view full memo visit: www.cms.gov

2022 100% GROUPS Thank you! ACADIANA RENAL PHYSICIANS CHILDREN’S CLINIC OF SOUTHWEST LOUISIANA IMPERIAL HEALTH WEST JEFFERSON EMERGENCY PHYSICIAN GROUP DERMATOLOGY ASSOCIATES OF SW LOUISIANA LAFAYETTE PEDIATRICS

LAKE CHARLES ANESTHESIOLOGY JEFFERSON RADIOLOGY ASSOCIATES THE FERTILITY INSTITUTE

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1971 – 2021

YEARS

THESE MEMBERS HAVE BEEN PHYSICIANS FOR

Dr. Christopher E. Cenac Dr. Farokh R. Contractor Dr. Miguel A. Culasso

Dr. Lester Wayne Johnson Dr. Roy Kadair Dr. Maximo B. Lamarche Dr. Jeffrey Moonan Dr. Lee R. Morgan Dr. Bennie P. Nobles Dr. Marco A. Ramos Dr. Allen C. Richert Dr. William A. Rolston

Dr. Robert K. Rush Dr. Jerry W. Sessions Dr. Samuel R. Staggers Dr. Thaddeus Lamar Teaford Dr. Lowery L. Thompson Dr. Paul Andrew Tibbits Dr. Joseph L. Tonore Dr. Walter D. Truax Dr. Jimmie Wayne Varnado

Dr. James P. David Dr. James R. Davis

Dr. William Jackson DeFee Dr. Kenneth W. Falterman

Dr. Michael C. Finn Dr. Frank B. Hughes

In Memoriam

THESE PHYSICIAN MEMBERS PASSED AWAY IN 2021

Dr. David W. Aiken Dr. Robert Albrecht Dr. Edward D. Baker Dr. James E. Ball Dr. William H. Brown Dr. Victor H. Feske Dr. William L. Geary Dr. Roy L. Gregory Dr. John H. Haynes Jr.

Dr. Richard C. Kamm Sr. Dr. Francis E. LeJeune Jr. Dr. Jill S. Lindberg Dr. Santo LoCoco Dr. Karoly G. Pinter Dr. Joseph Aaron Roy Dr. William K. Taylor Dr. Paul R. Winder

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LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

Earlier this year, LesterW. Johnson,MDageneral surgeon from Monroe, who also serves as professor of surgery at LSU Health-Shreveport and chief of surgery at LSU Health’s partner hospital University Health-Conway in Monroe, was elected as President of the Louisiana State Board of Medical Examiners. Dr. Johnson made the following comments upon assuming the president’s role on September 30, 2021.

If I may take just a moment of personal privilege to thank Governor Edwards and the State Medical Society for allowing me to serve on the board and of course to thank the board members for my opportunity to serve as your president. I must say that I take up this office and its tasks with buoyancy and hope for the future and with the highest possible admiration for my two predecessors who have held this office in the recent past. We surely owe a special debt of gratitude to both Dr. Valentine and Dr. Clark. I would hope that our deliberations would continue to be reflective rather than reactive and emulate those things worthy of emulation while avoiding those things worthy of avoidance. We must be respectful of this arena of ideas and hope for consensus but, as has always been our custom, avoid coercion. We should never confuse vigor of assertion with strength of argument. We can, I believe, all agree upon the value and indeed necessity of a solid organizational structure (and of course wemust thankDr. Clark for his efforts in this regard) but also, we should not diminish the importance of the individual initiative, inventiveness, and responsibility inherent upon each member of this board. Each of you were placed here for a reason, none of you should be the least bit shy, possessive, or proprietary about the products of your perception and intelligence. I look to each of you for ideas and where you deem warranted for your support. And if I may - - - in all the history of healthcare and its crises in Louisianawe here today surely inhabit a solemn hour. I have come to wonder over the last few days and nights how to best express the gratitude owed to all those who over the last eighteen months have

given so unselfishly of themselves in the battles with the covid virus and its variants. Surely no braver action can be asked than to deny that such circumstances are the natural lot of men. I happened upon a quote from the great novel “The Plague” by the French author and Nobel Prize winner Albert Camus which may do in attempt. I believe this passage is a primary reason for Camus’ Nobel Prize and expresses the timeless philosophy of those in healthcare who exhibit the broadest vision and those who contain the bravest hearts. Those who have always provided the North Star by which to steer us safely home to anchor. And I quote Albert Camus “Rieux knew that the tale he had to tell could not be one of final victory. It could be only the record of what had had to be done, and what assuredly would have to be done again in the never-ending fight against disease and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints, but refusing to bow down to pestilences, strive their utmost to be healers.” It has been said since the times of theGreat AntonineRoman Emperors that loyalty is the greatest virtue. Loyalty to the ideas and ideals of the medical profession is a sentiment not a law, it rests upon love not restraint. On behalf of the board of medical examiners of the state of Louisiana I would like to profusely thank our thirty thousand plus licensees, members of the nursing profession, members of the allied health professions, all first responders, and all other front- line colleagues for their loyalty to their profession and patients, and for their refusal to bow before pestilence in all its sordid forms. And now as has become our custom, a moment of silence for those lost. ■

T hank You Colleagues

10 J LA MED SOC | VOL 173 | WINTER 2021

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VALIDATE YOUR INFORMATION WITH MEDICAID EARLY The Louisiana Department of Health is asking all Medicaid providers to pay close attention to information sent this Fall. If you file claims with Louisiana Medicaid, you must enroll in the new Medicaid Provider Enrollment Portal to continue getting reimbursed. Even if you believe yourself to be enrolled, you need to validate your information. Enrollment ismandated by CMS and applies to any provider that provides care to Medicaid members, which includes current managed care organization (MCO) only providers, Dental Benefits Program Manager (DBPM) providers, Coordinated System of Care (CSoC) providers, existing fee- for-service providers, and any new providers enrolling for the first time. In Fall 2021, Louisiana Medicaid mailed letters to providers about this enrollment requirement. We are sending you this email because we want to make sure all of our providers complete enrollment timely. We don’t want anyone missing out on payment for services rendered.

To make things easier on you, the LSMS is working with Louisiana Medicaid to offer enrollment information that will focus on actions you need to take over the next few months. During this time, we will be sharing how you can access resources, training and answers to commonly The timelines shown by specialty are list on the following page.

SOME INFORMATION TO HAVE ON HAND:

• Web site: www.ldh.la.gov/medicaidproviderenrollment includes training webinars and frequently asked questions.

• If you received your letter from Louisiana Medicaid, follow the instructions provided.

• If you don’t have the letter, we have provided additional information to help you log in for enrollment in the frequently asked questions, below. • To help expedite your enrollment process, have information on hand to complete questions around disclosure of ownership. This is typically the most time consuming part of enrollment.

• Email: [email protected]

• Phone:

1-833-641-2140 (Monday – Friday, between 8 a.m. and 5 p.m. CST)

We will continue to share information as the need arises. Please reach out to [email protected] if you need additional information. ■

• If you have any questions or concerns, you can reach out to Louisiana Medicaid.

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To comply with federally mandated enrollment requirements, all providers that deliver services to Louisiana Medicaid members must be enrolled through the Louisiana Medicaid Provider Enrollment Portal to continue being reimbursed. To make things easier for providers, Medicaid is partnering with provider groups and provider associations to conduct provider-specific enrollment drives with provider-specific deadlines. This calendar outlines those enrollment drives and deadlines.

PROVIDER TYPE

ENROLLMENT DEADLINE

TARGETED OUTREACH TIMELINE

OBGYNs

December 27, 2021

November 29, 2021 – December 27, 2021

Primary care providers

December 28, 2021

November 30, 2021 – December 28, 2021

Pediatricians and pediatric specialists

December 29, 2021

December 1, 2021 – December 29, 2021

Specialists (orthopedic, cardiology, critical care, emergency medicine, oncology, hematology, radiology, ophthalmology, ENT/allergy/audiology, dermatology, endocrinology, gastroenterology, infectious disease, nephrology, neurology)

December 30, 2021

December 2, 2021 – December 30, 2021

Hospitals and their affiliated providers

January 31, 2022

January 3, 2022 – January 31, 2022

Rehabilitation/therapy – occupational, physical and speech

February 2, 2022

January 5, 2022 – February 2, 2022

Anesthesiologists

February 4, 2022

January 7, 2022 – February 4, 2022

Ambulance and NEMT

February 7, 2022

January 10, 2022 – February 7, 2022

Nursing homes

February 9, 2022

January 12, 2022 – February 9, 2022

ICFs and Pediatric Day Health Care providers

February 11, 2022

January 14, 2022 – February 11, 2022

Dentists and orthodontists

February 14, 2022

January 17, 2022 – February 14, 2022

Behavioral Health providers and specialists

February 16, 2022

January 19, 2022 – February 16, 2022

Durable Medical Equipment providers, dialysis providers and urgent care providers

February 18, 2022

January 21, 2022 –February 18, 2022

Pharmacy

February 21, 2022

January 24, 2022 - February 21, 2022

Hospice providers

February 23, 2022

January 26, 2022 – February 23, 2022

FCHCs, RHCs and OPH public health clinics

February 25, 2022

January 28, 2022 – February 25, 2022

J LA MED SOC | VOL 173 | WINTER 2021 13

LSMS MEMBERS APPOINTED TO LOUISIANA PATIENTS COMPENSATION FUND (PCF) OVERSIGHT BOARD

David M. Broussard, M.D Robert “Reece” Newsome, M.D.

MEDICAL REVIEW PANELS GROSS NEGLIGENCE STANDARD OF CARE Governor John Bel Edwards recently appointed Robert “Reece” Newsome, M.D., a Radiologist from Baton Rouge and David M. Broussard, M.D., an Anesthesiologist from Metairie each to a four-year term on the Louisiana Patients Compensation Fund (PCF) Oversight Board. This will be the first term for each. Dr. Newsome and Dr. Broussard join Luis M. Alvarado, M.D. (Internal Medicine – Mandeville) and Christopher M. Foret, M.D. (Family Medicine – Folsom) on the PCF Board where Dr. Foret currently serves as the current Chairman. ■

On November 18th, the Fifth Circuit issued this opinion denying plaintiff’s writ in the matter of In Re: Medical Review Panel Proceeding of Kathleen Welch . The court upheld Judge Schlegel’s grant of defendant’s motion and stated that the LHEPA “governs the standard of care for acts of malpractice by health care providers operating under a declared state of public health emergency” inferring that it is a modified or heightened standard of care. This supports the physician community’s arguments versus the suggestion from plaintiffs that the LHEPA merely offers an affirmative defense to be pleaded post-panel. There is another writ as well as an appeal pending relative to the non-qualified defendants. The LSMS is following these cases closely and will continue to provide you with the latest information as it becomes available. ■ Please contact Lauren Bailey, VP of Legal Affairs for additional information

There has been significant discussion and litigation relative the appropriate standard of care applicable during a declared state of public health emergency. Efforts by the physician community defense bar to seek a ruling that the panel chairs must instruct the panelists in the modified gross negligence standard under the LHEPA are ongoing. You may recall the letter brought to your attention in the November issue of Capsules which was sent by the Louisiana Association for Justice to medical review panel chairs stating that they are not inclined to use attorney chairpersons who intend to allow the medical review panels to apply the qualified immunity provisions of the Louisiana Health Emergency Powers Act, La. R.S. 29:771(B) (2)(c).

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14 J LA MED SOC | VOL 173 | WINTER 2021

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ABSTRACTS FROM THE LOUSIANA ACP WITH WINNERS AT ANNUAL MEETING MARCH 2021.2.2 Each year medical students from the four medical schools and residents from the eight Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual American College of Physicians (ACP) Meeting of the Louisiana Chapter. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to physician judges. This year a total of 119 abstracts were submitted for the meeting. Each judge scores each abstract independently and then the scores from all judges are averaged and ranked. This year we are excited to be able to publish the three most highly ranked abstracts presented at this year’s competition that were selected for oral presentations. An additional 20 abstracts are published online at https://online.flippingbook.com/view/88196473/5/. All abstracts were presented at the Associates Meeting held virtually due to the COVID-19 pandemic onMarch 13, 2021. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees.

Shane Sanne, DO, FACP Chair, Louisiana Associates Liaison Committee

Lee S. Engel, MD, PhD, FACP Past Governor, Louisiana Chapter ACP

Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP

NOT THE EXPECTED DIPLOCOCCI: A RARE CASE OF GONOCOCCAL INFECTIVE ENDOCARDITIS J Dubuc, D Montgomery, S Vignes Department of Internal Medicine, LSU Health Sciences Center, New Orleans, Louisiana INTRODUCTION Neisseria gonorrhoeae is a gram-negative diplococci bacteria responsible for over 80 million cases of urethritis in men and women every year. Infections rarely spread to distant sites such as skin, brain, joints, and even heart valves. Gonococcal endocarditis has been described in the literature fewer than 150 times, yet it portends a 19% mortality with 50% of cases requiring surgical intervention.

CASE A 56-year-old Caucasian man with a history of nephrolithiasis, coronary artery disease, and hypertension presented to the emergency department for 5 months duration of chest pain, fever, and chills. The chest pain was described as sternal intermittent aching pain with associated fevers, night sweats and rigors. The patient denied penile lesions, dysuria, and urethral discharge. Other pertinent history includes recent multiple laser lithotripsy procedures to treat nephrolithiasis. Temperature upon arrival to the emergency department was 100.1oF, physical examwas remarkable for a grade II/VI holosystolic murmur at the left mid-sternal border. Labs remarkable for WBC 8.4 10^3/uL ESR 77 mm/hr , CRP 9.7 mg/dL , and BNP 166 pg/mL On trans-thoracic echocardiogram a highly mobile 3.3x1.7cm vegetation on the septal leaflet of the tricuspid valve was visualized resulting in severe tricuspid regurgitation. On hospital day #2, blood cultures resulted positive for Neisseria gonorrhoeae . Empiric antibiotics were changed

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to Ceftriaxone 2g every 12 hours. On hospital day #8, the patient underwent tricuspid valve replacement with a mechanical valve. He was discharged on hospital day #14 with plans to complete a 6-week course of ceftriaxone. His course was later complicated by a pericardial effusion and supratherapeutic INR requiring emergent pericardiocentesis. enner Medical Center (OKMC), LSUHSC internal medicine had four medicine ward teams with one resident and one intern each took call every four days. There were two night float interns who rotated every three days. We also had five other house officers on consult rotations. DISCUSSION Gonococcal Endocarditis will inherently become increasingly common due to rising cases of gonorrhea STIs and antibiotic resistance. Identification of genitourinary infections and early effective treatment is imperative to prevent serious sequelae. In this case, genitourinary manipulation for treatment of nephrolithiasis in the setting of active gonococcal infection was likely the nidus of hematogenous spread. ■ RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB V Bolgiano, DO, D Cohen MD, S Walker MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) which may have distinctive mucocutaneous manifestations. Up to 33% of IBD patients have at least one extraintestinal disease manifestation. To our knowledge, this is the first case to describe success in treating MCD with certolizumab alone. CASE A 63-year-old woman with a previous history of Crohn’s disease presented to the dermatology clinic for evaluation of a rash located on her right upper lip. She reported that the rash appeared two years prior. It was associated with pruritus andmoderate swelling. Histopathological findings from a 4.0 mm punch biopsy revealed multiple nodular

granulomatous infiltrates extending from the superficial reticular to deep reticular dermis. The granulomas were composed of numerous histiocytes as well as a moderately dense inflammatory infiltrate made up predominantly of lymphocytes with scattered plasma cells and eosinophils. S-100 staining was negative. PAS and Fite stains were negative for infectious organisms. The patient had tried Humira, Imuran, Remicade, Plaquenil, Minocycline, and intralesional Kenalog with minimal improvements. This patient ultimately responded to the induction dose of 400 mg certolizumab (2 injections of 200 mg) and was prescribed a maintenance dose of 400 mg every other week that will require long-term follow up. DISCUSSION Metastatic Crohn’s disease is a rare, non-contiguous cutaneous manifestation of primary CD, being the least common presentation of extra-intestinal CD. Most cases of MCD occur on the lower extremities, intertriginous areas, face, and genital area. No clear correlation between the development of MCD and luminal disease activity has been established. Adalimumab, infliximab, antibiotics, systemic & topical corticosteroids, methotrexate, and azathioprine have demonstrated benefit in MCD. Certolizumab (certolizumab pegol) is a PEGylated anti-tumor necrosis factor biologic therapy approved for use in Crohn’s disease among other diseases. ■

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J LA MED SOC | VOL 173 | WINTER 2021 17

ACUTE ONSET OF HOARSENESS OF VOICE IN A MIDDLE AGED MALE PATIENT Jane A. Ball, Jagan D. Gupta MD Neel D. Gupta MD Jeremy B. Nguyen MD

HISTORY 56 year - old male presents with acute onset of hoarseness of voice. Patient states that he has had generalized weakness, difficulty swallowing, and mild gradual unintentional weight loss over the past 6 months.

Figure 1 Axial CT with contrast

Figure 2 Axial CT with contrast

Figure 3 Coronal CT with contrast

Figure 4 Axial CT with contrast

Figure 5 PET/CT fusion

Figure 4 Axial CT with contrast

Figure 6 Axial CT with contrast

Figure 7 PET/CT Fusion

IMAGING FINDINGS Figure 1 demonstrates ipsilateral dilatation of the right laryngeal ventricle (yellow arrow). Figure 2 and 3 demonstrate asymmetrical thickening and medialization of the right aryepiglottic fold (yellow arrow) and asymmetrical ipsilateral dilatation of the right piriform sinus (green arrow). Figures 4 and 5 demonstrate a heterogeneous soft tissue mass consistent with conglomerate mediastinal lymphadenopathy centered with the right paratracheal space extending superiorly to intimately involve the right recurrent laryngeal nerve (yellow arrow), the mass also exhibits marked increased metabolic activity on PET/CT fusion images (red arrow). Figures 6 and 7 show circumferential soft tissue thickening of the distal esophagus demonstrating increasedmetabolic activity on CT (yellow arrow) and PET/CT fusion images (red arrow)

DIFFERENTIAL DIAGNOSIS 1. Metastatic Primary Esophageal Neoplasm with Right Paratracheal/Mediastinal Metastatic Lymphadenopathy affecting the Right Recurrent Laryngeal Nerve resulting in Unilateral Vocal Cord Paralysis

2. Lymphoma

3. Unilateral Vocal Cord Paralysis/Paresis in the Setting of Prolonged Intubation.

4. Reactive Mediastinal Lymphadenopathy

5. Thyroid Goiter versus Thyroid lesion

6. Vascular Lesion such as Thoracic Aortic Aneurysm

7. Sarcoidosis

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FINAL DIAGNOSIS Metastatic Esophageal Carcinoma with Primary Neoplasm resulting in circumferential infiltration of the distal esophagus and resulting metastatic right paratracheal conglomerate lymphadenopathy extending superiorly encompassing and resulting in mass effect on the right recurrent laryngeal nerve. DISCUSSION Vocal cord paralysis (VCP) can cause both personal and social distress. An afflicted patient may experience dyspnea and labored breathing. VCP can cause hoarseness and affect a person’s ability to communicate with others. Often time the vocal cords are temporarily affected resulting in paresis, rather than paralysis. Our case presents VCP resulting from right paratracheal lymphadenopathy affecting the right recurrent laryngeal nerve. VCP results from damage to a recurrent laryngeal nerve (RLN), which are branches off the vagus nerves. The RLNs innervate all the intrinsic laryngeal muscles, excluding the cricothyroid and control movement of the vocal cords. 1 Damage to the vagal nerves proximal to the branch point of the RLNs as well as damage to the either RLNs themselves can result in VCP. VCP is a well-known complication of surgical procedures involving the neck to include thyroidectomy and carotid endarterectomy. After surgical procedures of the neck, patients are closely monitored for common presenting symptoms of VCP: dyspnea, hoarseness, and dysphonia. Other less common etiologies of VCP include trauma, infection, inflammation, other idiopathic causes, and external mass effect or impingement from a subjacent space occupying lesion. 2,3 Imaging offers confirmation of clinically suspected VCP and the opportunity to locate any underlying lesions and evaluate underlying etiologies. It has been noted that VCP may be a sign of a more serious pathology such as underlying malignancy. Without a doubt, imaging can be valuable in determining the cause and directing treatment. 1 Laryngoscopy provides direct observation of vocal cord mobility. Ultrasound is another modality by which the neck can be evaluated. 1 Laryngeal electromyography can confirmnerve injury. 2 For our casediscussion,we focusedon computed tomography (CT) and PET/CT imaging findings. The American College of Radiology (ACR) offers imaging modality recommendations for VCP evaluation based on the location of the lesion along the vagus nerve or RLN pathway. CT is recommended to evaluate the lower course of the vagus nerve. CT and magnetic resonance (MR) is recommended to evaluate the mid-neck and larynx. MR is

recommended to evaluate the upper course of the vagus nerve including the skull base. 3 Our patient underwent a pre and post contrasted CT examination of the neck. Dankbaar and Pemijer described the imaging findings of VCP which include ipsilateral laryngeal ventricle dilatation, ipsilateral aryepiglottic fold thickening and medial deviation of the aryepiglottic fold, ipsilateral piriform sinus dilatation, and ipsilateral paramedian position of the paralyzed vocal cord. 3 Imaging findings may be unilateral or bilateral depending on the location of underlying nerve injury or compromise. Our patient exhibited right- sided VCP secondary to conglomerate right paratracheal lymphadenopathy compromising the right RLN function. REFERENCES 1. Kwong Y, Boddu S, Shah J. Radiology of Vocal Cord Palsy. Clinical Radiology 2012 Nov;67(11):1108-14. 2. Stager S. Vocal Fold Paresis: Etiology, Clinical Diagnosis and Clinical Management. Current Opinion in Otolaryngology & Head & Neck Surgery: December 2014 - Volume 22 - Issue 6 – p 444–449. 3. Dankbaar JW, Pameijer FA. Vocal Cord Paralysis: Anatomy, Imaging and Pathology. Insights in Imaging. 2014 Dec;5(6):743-51. 4. Wippold, FJ, Cornelius RS, Aiken AH et al. ACR Appropriateness Criteria® Cranial Neuropathy: Vocal Cord Paralysis. Available athttps://acsearch. acr.org/docs/69509/Narrative/. American College of Radiology. Accessed 14 September 2016. ACKNOWLEDGMENTS Jane Ball is a 4th year radiology resident at Louisiana State University School of Medicine in New Orleans, LA. Jagan DewanGuptaMDisaclinical andacademicneuroradiologist in New Orleans and serves as adjunct clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Neel Dewan Gupta MD is a clinical and academic musculoskeletal radiologist in New Orleans and serves as a clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Jeremy Nguyen MD, FACR is clinical radiology professor within the Department of Radiology at the Tulane University Medical Center. Donald Olivares, Digital Imaging Specialist and Graphic Designer. ■

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