J-LSMS | Abstracts | 2021

J-LSMS | Abstracts | 2021

ABSTRACTS FROM THE 2021 LOUISIANA ANNUAL ACP MEETING

CONTENTS

JOURNAL EDITORIAL STAFF

EDITOR D. Luke Glancy, MD

ASSOCIATE EDITOR L.W. Johnson, MD

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AN ATYPICAL PRESENTATION: BELCHING AS A CHIEF COMPLAINT IN AORTIC STENOSIS-RELATED ANGINA NOT THE EXPECTED DIPLOCOCCI: A RARE CASE OF GONOCOCCAL INFECTIVE ENDOCARDITIS

CHIEF EXECUTIVE OFFICER JeffWilliams

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

6 TICAGRELOR INDUCED DIFFUSE ALVEOLAR HEMORRHAGE AFTER PCI INTERVENTION 7 A RARE CASE OF ADULT TYPE ALCAPA SYNDROME: TEN YEARS AFTER SUCCESSFUL SURGICAL REPAIR 8 SUBCUTANEOUS PANNICULITIS LIKE T-CELL LYMPHOMA PRESENTING WITH HLH 9 CEFEPIME NEUROTOXICITY IN THE SETTING OF NORMAL RENAL FUNCTION 10 AVOIDING TEE AND INVASIVE INTERVENTION IN LOW RISK PFO IN A CASE OF PARADOXICAL STROKE B BUNOL MD, K KINGSTON DM, O SAQQA MD, H SHI MD 11 THE TRAVELLING TICK: NEUROLOGICAL MANIFESTATIONS IN LATE TICK-BORNE ILLNESS 12 A CASE OF COVID-19 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME RESULTING IN NEW ONSET HEART FAILURE IN AN ADULT 13 A PECULIAR ENCEPHALOPATHY: A RARE CASE OF PNEUMATOSIS INTESTINALIS SECONDARY TO CYTOMEGALOVIRUS 14 A CASE OF SYPHILITIC AORTIC DISSECTION 15 CYTOPENIAS TO POLYCYTHEMIA VERA: AN UNUSUAL CASE 16 A CASE OF TRANSFUSION RELATED BACTERIAL INFECTION 17 DIAGNOSIS AND MANAGEMENT OF CARDIAC HEMOCHROMATOSIS 18 RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB 19 CNS MIXED FUNGAL BALL IN AN IMMUNOCOMPETENT PATIENT - A RARE ENTITY! 20 ABNORMAL PRESENTATION OF ADVANCED GESTATIONAL TROPHOBLASTIC NEOPLASM (GTN) WITH PULMONARY ARTERY OBSTRUCTIVE SYMPTOMS AND PROFOUND ANEMIA 21 CENTRAL RETINAL ARTERY OCCLUSION AND NEW ONSET ATRIAL FIBRILLATION 22 TREATMENT RESISTANT PROLACTINOMA: REASONS BEYOND NON-COMPLIANCE 23 A CASE OF STRONGYLOIDES IN AN IMMUNOCOMPROMISED PATIENT 24 ADENOSQUAMOUS CARCINOMA: AN ABNORMAL PRESENTATION OF A RARE MALIGNANCY 25 EDWARDSIELLA TARDA: A PISCINE CULPRIT OF ACUTE CHOLANGITIS 26 A RARE CASE OF PSEUDO-TMA IN A PATIENT WITH COBALAMIN DEFICIENCY

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, Vacant

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, Bennett Schmidt, MD Private Practice Physician Member, Vicki Steen, MD

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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 23 most highly ranked abstracts presented at this year’s competition that were selected for oral presentations.

All abstracts were presented at the Associates Meeting held virtually due to the COVID-19 pandemic on March 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

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AN ATYPICAL PRESENTATION: BELCHING AS A CHIEF COMPLAINT IN AORTIC STENOSIS-RELATED ANGINA T Dao, MD; J Edavettal, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Angina pectoris classically presents as a substernal squeezing chest pain associated with exertion and often related to coronary atherosclerotic disease. Occasionally, there can be atypical presenting symptoms including nausea, vomiting, and diaphoresis. Although gastrointestinal symptoms have been described in angina pectoris, high suspicion for cardiac etiology must be maintained due to potentially detrimental outcomes due to delayed diagnosis. CASE A 69-year-old man with tobacco abuse presented to internal medicine clinic with a 6-month history of abdominal bloating and episodic belching. He denied nausea or vomiting, but reported a sensation of dysphagia without weight loss. He denied chest pain but reported discomfort with exertion and meals that were relieved with belching, causing some food aversion. EKG showed no conduction, rhythm, ST segment or T wave abnormalities. At the time he was started on esomeprazole for treatment of gastroesophageal reflux which initially provided relief but eventually did not resolve his symptoms. Esophagogastroduodenoscopy was showed no esophageal abnormalities. Biopsies were negative for H pylori. A systolic murmur was heard on exam prompting an echocardiogram which showed an ejection fraction of 65%, aortic stenosis with a dilated left atrium, an aortic valve area of 0.86 cm 2 and a peak velocity of 3.42m/s. He was referred to cardiology for surgical aortic valve replacement evaluation. Coronary angiogram showed 70% stenosis of an ostial lesion in the circumflex artery. He underwent a coronary artery bypass as well as a surgical bioprosthetic aortic valve replacement. At 6-week follow up, he reports that his symptoms have largely resolved including his belching symptoms. DISCUSSION Although uncommon, belching and dysphagia can be concerning for esophageal disease but cardiac pathology must be maintained on the differential. In a patient with cardiac risk factors and gastrointestinal symptoms that resolved with surgical intervention, belching may be observed as early symptom of angina warranting further investigation.

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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 100.1 o F, physical exam was 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 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. 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.

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TICAGRELOR INDUCED DIFFUSE ALVEOLAR HEMORRHAGE AFTER PCI INTERVENTION

H Sajjad, MD, R Chan, MD, R Panicker, MD, S Shahid, MD, WD Brown, MD, M Fashho, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA

INTRODUCTION Diffuse alveolar hemorrhage (DAH) is a medical emergency that must be immediately recognized and treated. DAH is characterized by bilateral pulmonary infiltrates, hypoxia, hemoptysis, and/or falling blood count. Treatment ranges from supportive measures, to withdrawal of offending agents, steroid administration, plasmapheresis, and/or direct immunosuppression. CASE A 56 -year-old woman with a history of hypertension, hyperlipidemia, diabetes, and tobacco abuse presented with one- week of episodic, sharp, pressure-like, substernal chest pain that worsened with activity. EKG at admission revealed sinus tachycardia with ST elevations in the infero-lateral leads and elevated troponin-I. She was given Aspirin, started on a heparin drip, and underwent emergent percutaneous coronary intervention with a drug eluding stent to the right coronary artery and the circumflex artery. Post-procedure she was bolused with tirofiban, loaded with ticagrelor, and transferred to the intensive care unit. The following day she was started on dual antiplatelet therapy (DAPT) with Aspirin and Brilinta, Lopressor, and Atorvastatin. Overnight she developed dyspnea and hemoptysis. CT Angiography revealed diffuse bilateral infiltrates. Labs revealed hyponatremia, elevated BNP, and hemoglobin decrease from 13.5 to 11.5. She became febrile, tachycardic, and tachypneic with leukocytosis. Broad spectrum antibiotics were started. Chest x-ray revealed worsening bilateral opacities concerning for DAH. Brilinta was immediately discontinued and replaced with Plavix. Exam was significant for bilateral rhonchi and coarse breath sounds. Ultimately, she was intubated for acute hypoxemic respiratory failure, DAPT was discontinued, and methylprednisolone administered. She was extubated after a bronchoalveolar lavage, which revealed blood-tinged aspirate without signs of active bleeding. Aspirin and Plavix were restarted once her hemoptysis resolved. Her dyspnea improved and she was discharged home with oxygen. She is awaiting pulmonology and cardiology follow-up. DISCUSSION This case highlights the need for immediate recognition of Ticagrelor induced DAH and discontinuation of therapy in preventing life threatening progression to acute hypoxic respiratory failure.

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A RARE CASE OF ADULT TYPE ALCAPA SYNDROME: TEN YEARS AFTER SUCCESSFUL SURGICAL REPAIR A Gaddam MD, B Swirsky MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA INTRODUCTION Anomalous left coronary artery from the pulmonary artery (ALCAPA) Syndrome is a very rare congenital heart disease where the left coronary artery (LCA) originates from the pulmonary artery. It affects 1 in every 300,000 live births in the USA and if left untreated, has a 90% mortality within the first year of life. CASE DESCRIPTION: A 32-year-old woman with a past medical history of hypertension, non-insulin-dependent type 2 diabetes mellitus, hyperlipidemia, with no family history of heart disease presented with complaints of exertional angina since 2 years and had a normal physical examination. Further work-up with coronary angiography showed an anomalous left coronary artery arising from the pulmonary artery. Coronary angiographic findings also revealed a large voluminous right coronary artery (8 mm in diameter) with extensive collaterals to the left coronary artery. Transthoracic Echocardiogram revealed an ejection fraction of 40%withmild left ventricular hypertrophy. EKG showed nonspecific T wave abnormality in lateral leads. Our patient underwent surgical repair with coronary button transfer procedure without any perioperative complications. After 10 years of post repair, our patient is asymptomatic with and ejection fraction of 45% on Transthoracic Echo. DISCUSSION: In extremely rare cases of adult type ALCAPA Syndrome, those who live to adulthood have extensive collateral circulation from the right coronary artery and develop chronic myocardial ischemia resulting in arrhythmias, congestive heart failure, and sudden cardiac death. The extent of myocardial ischemia is determined by the development of collaterals between the right and left coronary artery. Diagnosis is usually established with coronary angiography, cardiac MR imaging, multi detector CT angiogram. Surgical correction with coronary button transfer procedure has excellent long-term results.

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SUBCUTANEOUS PANNICULITIS LIKE T-CELL LYMPHOMA PRESENTING WITH HLH C Sullivan, MD MSc, A Loghmani, DO, A Abbas MD, K Thomas, MD MSc, H Hall MD, G Destin DO, S Guillory MD, S Walvekar MD, R Chowdry, MD Department of Internal Medicine, LSU Health Sciences Center, New Orleans, Louisiana CASE: A 34-year-old man with no past medical history presented with two months of a rash on his lower back and daily fevers up to 103°F. Additionally he had fatigue and loss of appetite resulting in an 18-pound weight loss. He had previously been treated with sulfamethoxazole-trimethoprim and clindamycin for presumed cellulitis. He had erythematous indurated dusky plaques on his right neck, bilateral lower back and hips, right upper abdomen and groin, which were not painful, or pruritic. He also had faint erythematous pink macules scattered on his trunk and bilateral upper extremities. His lab work revealed elevated liver enzymes, cytopenia, ferritinemia, hypertriglyceridemia, and increased levels of soluble IL-2 receptors. These findings along with fevers and hemophagocytosis seen on skin biopsy met criteria for hemophagocytic lymphohistiocytosis (HLH). Further evaluation of the skin biopsy led to a diagnosis of subcutaneous panniculitis like T-cell lymphoma (SPTCL) alpha/beta subtype. He was started on cyclosporine 5mg/kg/day and dexamethasone 20mg/day. The patient noted almost immediate improvement is his skin lesions and laboratory abnormalities trended towards patient’s baseline within two weeks. DISCUSSION: SPTCL typically presentswith erythematous painless plaques and nodules on the trunk and extremities. Systemic symptoms include fever, chills and weight loss. Cytopenia and elevated liver enzymes are common. The two types of SPTCL are alpha/ beta and gamma/delta with the former being the less aggressive. STPCL presenting with HLH portends worse outcomes. Historically, many of these cases were treated with aggressive cytotoxic chemotherapy including cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate and prednisone (CHOP) based regimens; however, patients frequently relapse. There is no standardized treatment for SPTCL but previous studies suggest successful treatment with systemic steroids and cyclosporine. CONCLUSION: Our findings suggest that HLH secondary to SPTCL may be treated with cyclosporine and dexamethasone to achieve rapid clinical and symptom management of this rare malignancy.

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CEFEPIME NEUROTOXICITY IN THE SETTING OF NORMAL RENAL FUNCTION Abigail H. Boudreaux, MD PGY-1 Department of Medicine, Ochsner Medical Center, New Orleans, LA INTRODUCTION Antibiotics are some of the most prescribed medications in the inpatient setting. Although the profound benefits of treating infections often outweigh the potential adverse effects of antimicrobial administration, it is important to be aware of iatrogenic causes of new problems in the hospital. Beta-lactams such as penicillins and cephalosporins have been known to cause neurotoxicity. CASE: An 81-year-old man with a cerebral vascular accident without residual deficits, newly diagnosed hepatocellular carcinoma, and alcohol use disorder with last drink 2 weeks ago presented with lower back pain. MRI was suspicious for lumbar osteomyelitis/discitis. Empiric treatment for osteomyelitis with vancomycin and piperacillin-tazobactam was initiated, whichwas narrowed to vancomycin and cefepime while awaiting biopsy. The patient’s mental status on admissionwas fully alert and orientedwhich progressively changed to complete disorientation by day five. Initial workup of his encephalopathy was significant only for hyponatremia of 131 (patient had been without good food intake). Vital signs, other electrolytes, renal function, complete blood count, lactate, ammonia were all within normal limits. Computed tomography of the head was without convincing evidence of large hemorrhage or midline shift. Electroencephalogram obtained was negative for seizures, but demonstrated frequent triphasic waves, suggestive of metabolic encephalopathy. Due to growing clinical suspicion for cefepime neurotoxicity and grossly negative workup for other causes of metabolic encephalopathy, the patient was transitioned to ceftriaxone. By 48 hours, he was completely back to his baseline. DISCUSSION: Cefepime neurotoxicity is thought to be due to concentration-dependent GABA receptor antagonism. While most commonly seen among patients with renal impairment, a systemic review suggested cefepime toxicity in the setting of normal renal function may be more likely to occur in patients with pre-existing brain damage, possibly due to increased blood-brain barrier permeation. Our patient had history of substance abuse and prior stroke. It may have been interesting to obtain a serum or CSF cefepime concentration before discontinuation of the drug as toxic trough levels have been proposed in literature. One paper proposed therapeutic drug monitoring targeting troughs of