J-LSMS 2022 | Summer

J-LSMS 2022 | Summer

JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 174 | ISSUE 1 | SUMMER 2022

SINE DIE: 2022 LEGISLATIVE SESSION IS A WRAP

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VOL 174 | ISSUE 1 | SUMER 2022 CONTENTS

CHIEF EXECUTIVE OFFICER Jeff Williams

JOURNAL BOARD K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD

4 “ASK WHAT YOU CAN DO FOR YOUR PROFESSION!” 5 FROM AROUND THE STATE 6 MEWA ANNOUCEMENT: SAVE 10-15% 8 GROWING SOFT TISSUE MASS WITHIN THE RIGHT GROIN OF A YOUNG MALE PATIENT 10 STUDENT ABSTRACTS

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 2 Member, Vacant 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 SECTION REPRESENTATIVES Senior Physician Member, Marcus Pittman, III, 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

10 RESIDENT ABSTRACT WINNERS 11 STUDENT ABSTRACT WINNER

12 LAMPAC MEMORANDUM 14 LEGISLATIVE RECEPTION 15 WHITE COAT WEDNESDAY

16 2022 REGULAR LEGISLATIVE SESSION IS A WRAP 19 2022 LEGISLATIVE SESSION: BY THE NUMBERS 20 ADMINISTRATIVE SIMPLIFICATION BILLS 22 VACCINATIONS IN 2022 23 2022 VACCINATION RELATED LEGISLATION

J LA MED SOC | VOL 174 | SUMMER 2022 3

With the 2022 Louisiana Regular Legislative Session coming to a close, we have much to be grateful for as a profession and many to thank. As the Chair of the Council on Legislation for the Louisiana State Medical Society, I want to start by thanking you, the members, for responding to our ask for your participation and for making your voice heard in Baton Rouge this past year. Early in the session, we hosted the 2022 Legislative Reception and White Coat Wednesday events. While the details of these events will be chronicled elsewhere, suffice it to say that for two years in a row, we have “outgrown the facility” based upon your turnout and willingness to engage. With well over 120 members in attendance this year, there can be no doubt that our society is experiencing a new “finest hour” of professional advocacy. Next to thank is your Council on Legislation. This is the committee or “council” of the society, made up of individual members (one from each District), who work year-round to ensure success when the legislative session arrives. In addition to attending the fifteen plus meetings we hold every year, they offer strategy and insights into key issues and relationships at the Capitol based, in many cases, on decades of experience in the Legislative process. We do Sunday evening conference calls throughout session in addition to the three or so other meetings we hold on your behalf each year. You would be incredibly proud of your fellow members if you witnessed the commitment they bring to the table in this effort. They are truly advocacy warriors for the profession! I would also be remiss if I didn’t highlight the incredible work of our LSMS Governmental Affairs team, especially Maria Bowen, our Vice President of Governmental Affairs and Lauren Bailey, our Vice President of Legal Affairs. They work tirelessly, year- round, but especially during session, to ensure your objectives, as described in LSMS policy, are achieved. Maria has completed her fourth session now with the LSMS, but it is hard to imagine where we would be without her. When she joined, we discussed how priority number one would be to re-engage the grassroots membership of the LSMS. I am comfortable, based upon the success of White Coat Wednesday, in saying that this crucial first step is achieved. “ASK WHAT YOU CAN DO FOR YOUR PROFESSION!” DAVID BROUSSARD, MD - Council on Legislation for the Louisiana State Medical Society, Chair

I do get asked by members throughout the year what they can do to help become better advocates for the profession. There is no question that the answer is to form a relationship with your individual state Senator and Representative and support them politically. Starting such a relationship is easiest to accomplish with a first-time candidate, but in my experience, even established elected officials are surprisingly receptive if you reach out to them outside of the time-crunch of the legislative session. Many of you are already aware of the members from growing up together or interacting casually in your personal lives, so that makes the introductions easier. It also helps if the first time you are reaching out to them, you simply introduce your profession along with some of your “feel good” priorities (making telemedicine better or helping with the opioid epidemic, as examples) and don’t have a specific “ask.” This budding relationship will be developed even further when you have the opportunity to work on or contribute to their next campaign. These efforts don’t bring a direct return, but will help you in getting their attention during the busy season of session and at least allow you the opportunity to articulate your position on ways to help improve legislation they are considering.

Don’t hesitate to approach me at the upcoming LSMS House of Delegates in August if you have questions and want to get more involved in professional advocacy. We will no doubt face big challenges in the coming years and we will need you at the table with us!

THERE IS NO QUESTION THAT THE ANSWER IS TO FORM A RELATIONSHIP WITH YOUR INDIVIDUAL STATE SENATOR AND REPRESENTATIVE AND SUPPORT THEM POLITICALLY.

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Creating & Retaining a High-Functioning Team Tuesday, May 3, 2022

Drs. Steen Trawick & Christina Notarianni

Drs. Joseph Bochinni & John Vanchiere

Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high-functioning healthcare team. The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high- functioning healthcare team. Drs. Steen Trawick & Christina Notarianni Drs. Steen Trawick & Christina Notarianni Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. FROM AROUND THE STATE QUARTERLY MEETING & 1-HOUR CME CREATING & RETAINING A HIGH-FUNCTIONING TEAM TUESDAY, MAY 3, 2022 Quarterly Meeting Creating & Retaining a Hig Tuesday, May 3

Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System Meeting and 1-hour CME at the WK Eye I physicians in attendance earned 1 hour of bar and their choice of either filet or snapp Drs. John Bienvenue & Stephen White The guest speaker was Teri Deabler, CM consultant at the Texas Medical Associatio in healthcare management, Teri kept every on how to create a high-functioning health

Quarterly Meeting & 1-Hour CME Creating & Retaining a High-Functioning Team Tuesday, May 3, 2022

Dr. Ellie Hudnall & Casey Richer

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Drs. Joseph Bochinni & John Vanchiere Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. Drs. John Bienvenue & Stephen White Drs. John Bienvenue & Stephen White The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high-functioning healthcare team. Dr. Ellie Hudnall & Casey Richer Dr. Ellie Hudnall & Casey Richer Drs. John Bienvenue & Stephen White

Drs. Steen Trawick & Christina Notarianni Drs. Steen Trawick & Christina Notarianni

Drs. John Bienvenue & Stephen W

Dr. Ellie Hudnall & Casey Richer Dr. Ellie Hudnall & Casey Richer Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White

Thanks for supporting th Thanks for supporting the NLM Thanks for supporting the NLMS!

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Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bickn Dr. Stephen

Nearly 50 in attendance for the 1-hour CME

Nearly 50 in attendance for the 1-hour CME

Nearly 50 in attendance for the 1-hour CME

Thanks for supporting the NLMS! Thanks for supporting the NLMS!

Nearly 50 in attendance for the 1-hour CME Nearly 50 in attendance for the 1-hour CME

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4 Drs. John Bienvenue & Stephen White 5 Nearly 50 in attendance for the 1-hour CME 6 Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan

Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell 7 Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White 8 Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell

Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell 1 Drs. Steen Trawick & Christina Notarianni 2 Drs. Joseph Bochinni & John Vanchiere 3 Dr. Ellie Hudnall & Casey Richer

Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White

J LA MED SOC | VOL 174 | SUMMER 2022 5

MEWA ANNOUCEMENT: SAVE 10-15%

The Louisiana State Medical Society is pleased to announce our vision to deliver a LSMS- sponsored health plan to our members is becoming a reality. The Louisiana Department of Insurance is currently reviewing our application to provide health insurance to our members through a Multiple Employer Welfare Arrangement (MEWA.) Known as Advantage Physicians Healthcare Trust (APHT), we anticipate our plans will be approved this summer.

APHT will offer three health insurance plans to LSMS members that are closely modeled after existing Blue Cross Blue Shield of Louisiana (BCBS of LA) plans. BCBS of LA will serve as our claims administrator. Eligibility for the APHT health insurance plans includes:

1 APHT health insurance coverage is only open to active members of the LSMS, their families and full-time employees of their practices and their families. 2 APHT health insurance coverage is only open to residents of Louisiana. 3 At minimum of two subscribers in the practice must participate. As an example, a sole practitioner with a single full- time staff member participating is the smallest subgroup that we can accept. 4 To broaden the reach of the APHT health plans (and achieve lower costs), we have created a new category of membership in the LSMS – Affiliate Member. Any dentist licensed by the Louisiana State Board of Dentistry, or any medical professional licensed by the Louisiana Board of Medical Examiners, will be eligible for an Affiliate Membership in the LSMS, and may participate in APHT health plans and use our purchasing site. 5 Although the APHT health plans are modeled after three existing BCBS of LA plans, our goals is to reduce costs for a large majority of our members than the traditional BCBS of LA plans as applicants will be fully underwritten before coverage is initiated. Underwriting was common before the Affordable Care Act, but it will allow us to more accurately assess the risks associated with covering subscribers to our plans. 6 APHT health plan members will have complete access to the existing BCBS of LA network of providers and will carry a health insurance card co-branded with BCBS of LA and APHT logos. If you are currently a BCBS of LA member, your coverage will remain unchanged.

7 Unlike traditional health insurance plans, APHT plans can be purchased by LSMS members on an annual basis throughout the year – no more waiting for open enrollment. All plans started during the year will have a renewal date of January 1 the following year. 8 APHT is overseen by a group of five trustees drawn from the executive leadership of the LSMS its general membership. The primary objective of APHT and our board of trustees is to secure the lowest possible health care premiums with the broadest possible coverage for LSMS members. 9 You can obtain quotes and purchase APHT plans three ways. 1 Through your existing insurance broker relationships. 2 Contact the LSMS directly for an introduction to a DOI- licensed broker. 3 Visit the APHT website at www.aphtrust.com to complete you application electronically. The website will go live shortly after our application is approved by the DOI. 10 Finally, we have licensed and customized state-of-the-art health insurance back-end software to allow us to seamlessly automate the entire health insurance application, quoting, invoicing and payment processes. Through many months working diligently with insurance advisors, lawyers, actuaries, underwriters, Blue Cross Blue Shield of Louisiana, and our financial partners we are able to bring this dream to life. We encourage all of our members to apply for health insurance coverage through APHT so that we can grow and maintain this benefit for our membership for many years into the future.

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J LA MED SOC | VOL 173 | WINTER 2021

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GROWING SOFT TISSUE MASS WITHIN THE RIGHT GROIN OF A YOUNG MALE PATIENT Mitchell Ta, BS, Ahmed T. Rashad, MD, Neel D. Gupta, MD, Jeremy B. Nguyen, MD HISTORY 29 year- old male presents with 2 months of groin pain. Physical exam demonstrates a soft tissue mass within the right groin, which has increased in size.

Figure 1: Axial T1 MRI

Figure 2: Axial T2 MRI

Figure 3: Axial STIR MRI

F igure 4: Axial contrast-enhanced T1

Figure 5: Coronal contrast-enhanced T1

Figure 6: Axial CT

Figure 7: Axial FDG-PET fusion

Figure 7: FDG-PET with 3D ROI (MIP)

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IMAGING FINDINGS Figure 1

4 varieties – typical, myxoid (high water content), lipoma-like (containing adult fat, common in the thigh), and spindle cell 1,2 .

Well-circumscribed heterogenous T1 hyperintense right adductor intra/extramuscular mass with fat signal characteristics. Figure 2 Well-circumscribed heterogenous T2 hyperintense right adductor intra/extramuscular mass with fat signal characteristics. Figure 3 Well-circumscribed heterogenous STIR hyperintense right adductor intra/extramuscular mass. Figure 4 Well-circumscribed heterogeneously enhancing right adductor intra/extramuscular mass. Figure 5 Well-circumscribed heterogeneously enhancing right adductor intra/extramuscular mass.

Radiographs, Ultrasound with doppler interrogation, CT, and MRI are viable modalities to help differentiate hibernomas. On radiographs, hibernomas often appear as radiolucent masses without mineralization or osseous abnormalities. On ultrasound, hibernomas present as well-circumscribed, hyperechoic masses, with Doppler demonstrating hypervascularity. Arteriovenous (AV) shunting within hibernomas has been reported. AV shunting as well intrinsic hypervascularity, contraindicates core needle biopsy, especially involving deep lesions. The characteristics of hibernomas on imaging likely parallel the histological variants described earlier. Typical hibernomas demonstrate multiple prominent branching serpentine vascular structures on CT and MRI with low signal intensity on all MR pulse sequences. Lipoma- like (or spindle cell if located within the neck) hibernomas appear identical to fat on CT and MRI but with branching vascular structures. Myxoid type hibernomas, meanwhile, present with high water content 1,2 . Definitive treatment is resection. However, in terms of surgical resection in our case, the mass was also displacing muscle. Along the proximal deep lateral margin of the mass, one of the branches of the obturator nerve appeared to course directly into the tumor and was not salvageable. Additionally, there was an unusual area of fat collection at this same site. This collection was sent as a separate specimen to ensure that all of the tumor was resected and that no residual tumor tracked proximal along the obturator nerve. Pathology confirmed that there were fragments of hibernoma within the separate specimen. These lesions, however, have not been shown to recur, metastasize or develop into malignancies in the literature 1-3 . REFERENCES 1. Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, Kransdorf MJ. From the archives of the AFIP: benign

Figure 6 Well-circumscribed hypodense right adductor intra/ extramuscular mass.

Figure 7 Axial FDG-PET/CT fused images demonstrating significant FDG uptake within the right adductor musculature. Figure 8 3D Coronal PETCT MIP with significant abnormal uptake within the region of interest (Right Adductor Musculature) with SUV 18.7. Physiologic radiotracer uptake within the left ventricle myocardium, renal collecting system and the urinary bladder. DIFFERENTIAL DIAGNOSIS

musculoskeletal lipomatous lesions. Radiographics. 2004;24(5):1433-1466. doi:10.1148/rg.245045120

1. Hibernoma 2. Liposarcoma 3. Nonspecific Lipomatous Mass 4. Rhabdomyoma 5. Resolving hematoma FINAL DIAGNOSIS: HIBERNOMA DISCUSSION

2. Furlong MA, Fanburg-Smith JC, Miettinen M. The morphologic spectrum of hibernoma: a clinicopathologic study of 170 cases. Am J Surg Pathol. 2001;25(6):809-814. doi:10.1097/00000478-200106000-00014 3. Fnini S, et al. Hibernoma of the thigh. Ann Chir Plast Esthet 2011 Apr; 56(2):160-2. ACKNOWLEDGMENTS Mitchell Ta is a 4th year Medical Student at Tulane University School of Medicine in New Orleans, La. Ahmed T. Rashad MD is a PGYIII Resident in the Department of Radiology at Tulane University School of Medicine in New Orleans, La. 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. ■

Hibernomas, named for resembling the brown fat of hibernating animals in 1914, are rare, benign fatty lesions that arise from vestigial fetal brown fat 1 . They are often painless and slow- growing. On physical exam, hibernomas are typically mobile, pliable masses that are warm to the touch, secondary to their hypervascularity. Macroscopically, they resemble lipomas in that they are largely well-circumscribed, encapsulated fatty lobulated masses that typically measure 5 to 10 cm in diameter. In terms of their incidence, hibernomas are most often seen in the 3rd or 4th decades of life with a slight female predominance. Hibernomas appear where normal brown fat occur, most commonly in the thigh 3 , occasionally in the shoulder, back, neck, chest, arm, and rarely within the retroperitoneum. Histopathologically, hibernomas have been categorized into

J LA MED SOC | VOL 174 | SUMMER 2022 9

STUDENT ABSTRACTS

Each year medical students from the five 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) Resident and Student 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 resident council judges. This year a total of 117 abstracts were submitted for the meeting. We are excited to be able to publish the three resident and the sole student winning presentations at this year’s competition selected by a panel of judges. All abstracts were presented at the Associates Meeting held virtually due to the COVID-19 pandemic on January 22, 2022. 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 Co-Chair, Louisiana Associates Liaison Committee Miranda Mitchell, MD Co-Chair, Louisiana Associates Liaison Committee Shahzeem Bhayani, MD Co-chair, Louisiana Student Liaison Committee Catherine Hebert, MD, FACP Co-Chair, Louisiana Student Liaison Committee Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP

RESIDENT ABSTRACT WINNERS BILATERAL THALAMIC GLIOBLASTOMA MULTIFORME PRESENTING WITH APHASIA G Unis MD, E Philon DO Department of Medicine, Ochsner Medical Center, New Orleans, LA

INTRODUCTION: Bilateral thalamic lesions on brain Magnetic Resonance Imaging (MRI) represent a unique and unusual radiographic pattern. While unique, the differential for bilateral thalamic lesions is broad and can include cerebrovascular disease, toxin or metabolic syndromes, posterior reversible encephalopathy syndrome, viral infections, and neo- and paraneoplastic processes. CASE: A 55-year-old male with hypertension and type 2 diabetes presented with an acute aphasia of 5 hours in duration and general malaise prior to admission but denied other significant symptoms. Physical examination at the time of admission was negative for neurological abnormalities including cranial nerve testing, as well as being fully alert and oriented with appropriate mentation. He was afebrile, slightly hypertensive with a blood pressure of 149/96, and without oxygen requirements. Laboratory studies were within normal limits on admission however, computed tomography of the head demonstrated Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: Hyperammonemia is often the result of liver pathology. When hyperammonemia is not the result of liver disease, an occult disorder of metabolism must be on the differential for unexplained hyperammonemia, such as a urea cycle disorder. CASE: A 57-year-old man with recovered systolic heart failure, atrial fibrillation, hypertension, and cervical neck fracture status post recent cervical spine corpectomy and fusion presented with worsening dysphagia and neck discomfort and was found to have a cervical fluid collection. He had no known underlying liver disease and denied significant alcohol history. He received a dexamethasone taper and a lumbar drain. He was later admitted to the intensive care unit (ICU) for unstable atrial fibrillation with

subtle diminished density within the left thalamus. MRI imaging of the brain demonstrated bilateral thalamic enlargement with diffuse T2/FLAIR signal hyperintensity. Lumbar puncture was obtained and routine cerebral spinal fluid (CSF) studies in addition to viral, bacterial cultures, and autoimmune studies were ordered. The patient was found to be positive for West Nile Virus (WNV) but with a negative WNV polymerase chain reaction (PCR) and toxoplasmosis IgG positive results. The patient was treated empirically for toxoplasmosis but failed to improve. Repeat MRI was obtained and demonstrated new enhancement which prompted a brain biopsy of the temporal lobe. Pathology showed WHO Grade IV glioblastoma multiforme and the patient was referred to oncology.

DISCUSSION: This rare and unusual disease, while previously described in the literature highlights the broad differential for bilateral thalamic lesions found on brain MRI and represents a unique learning case. SEVERE NONCIRRHOTIC HYPERAMMONEMIA: WHAT UREA-LLY SHOULD CONSIDER S Wu, C Basilio MD, MPH

rapid ventricular rates. In the ICU, the patient became more somnolent and was unable to follow commands. Encephalopathy workup revealed elevated BUN with normal creatinine, ammonia of 772, and mildly elevated transaminases. Liver workup was normal. Workup for inborn errors of metabolism showed mildly decreased citrulline. Urine and plasma amino acids were otherwise normal. His hyperammonemia resolved and his mentation improved with lactulose three times daily and rifaximin twice daily. Urea cycle disorder gene panel and further genetic workup is ongoing. Patient will follow up with genetics after discharge.

DISCUSSION: Patients with elevations of ammonia present with encephalopathy, which may progress quickly to cerebral

10 J LA MED SOC | VOL 174 | SUMMER 2022

herniation. Survival requires immediate reduction of ammonia levels. Although the differential for hyperammonemia is broad, inborn errors of metabolism (IEM), like a urea cycle disorder, should be considered when hyperammonemia is of unclear etiology. Although IEMs often have early age of onset, urea cycle disorders have multiple modes of inheritance and can present

at later stages. IEMs may also be unmasked by steroid therapy, which is plausible in this patient who was on a steroid taper prior to his hyperammonemic state. Treatment for a potential IEM begins prior to confirmation of an etiology. Geneticists should be consulted early on for evaluation and management.

MASQUERADING AS TTP: AN INSIDIOUS PRESENTATION OF B12 DEFICIENCY M Zoya MD, M N Salloum MD Department of Medicine, Louisiana State University, Shreveport, LA

INTRODUCTION: Pseudothrombotic microangiopathy is a rare presentation of B12 (cobalamin) deficiency. Patients appear ill with elevated reticulocyte count, lactate dehydrogenase (LDH), and total bilirubin with low haptoglobin, platelet count, and anemia - deceivingly suggestive of thrombotic thrombocytopenic purpura (TTP), a type of true and deadly microangiopathic hemolytic anemia. CASE: A 36-year-old female with hypothyroidism presented for anemia with a hemoglobin of 5.1 g/dL and symptoms of fatigue, shortness of breath, palpitations, sweats, chills, vomiting, 54 lb weight loss, easy bruising and tingling in her fingertips and toes for one month. Exam was unremarkable other than pallor. She was found to have an LDH >4,000, haptoglobin