J-LSMS | Abstracts | 2020

J-LSMS | Abstracts | 2020

ABSTRACTS FROM THE 2020 LOUISIANA ANNUAL ACP MEETING

CONTENTS

JOURNAL EDITORIAL STAFF

EDITOR D. Luke Glancy, MD

ASSOCIATE EDITOR L.W. Johnson, MD

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A CASE OF THYROTOXICOSIS INDUCED PERIODIC PARALYSIS

CHIEF EXECUTIVE OFFICER JeffWilliams

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A CASE OF REGORAFENIB INDUCED PANCREATITIS: A RARE ADVERSE EVENT OF TYROSINE KINASE INHIBITORS

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

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RESOLVING HEMI’S, INDUCING STEMI’S

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HEMORRHAGIC BULLAE AS A PRESENTATION OF PHLEGMASIA CERULEA DOLENS WITH MAY-THURNER SYNDROME IT’S NOT ALWAYS TUBERCULOSIS! TREE-IN-BUD OPACITIES LEADING TO A DIAGNOSIS OF PULMONARY SARCOID

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

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9 HEPATIC SCHISTOSOMIASIS FOUND IN EXPLANTED LIVER POST-TRANSPLANT 10 ACCUSTOMED TO INFECTION 11 UNUSUAL PANCREATIC MALIGNANCY 12 RECURRENT RHABDOMYOLYSIS 13 I DON’T WANT TO SEE A DOCTOR; THEY FREAK OUT LOOKING AT MY LABS: A CASE OF MAY-HEGGLIN SYNDROME 14 A NEW HAND FINDING THAT COULD POINT TOWARD LIVER DISEASE 15 SOCIAL MEDIA AND A CASE OF ANAPHYLAXIS 16 A CASE OF PURTSCHER’S RETINOPATHY SECONDARY TO ACUTE ALCOHOL INDUCED PANCREATITIS 17 A RARE PRESENTATION OF DEVIC’S DISEASE 18 ACUTE CORONARY SYNDROME FOLLOWING THERAPEUTIC EPINEPHRINE FOR ANAPHYLAXIS. 19 THE ABDOMINAL COCOON SYNDROME: A CASE REPORT 20 HONEY, I SHRUNK THE LUNGS 21 PSEUDOANEURYSM OF THE MITRAL-AORTIC INTERVALVULAR FIBROSA DUE TO MITRAL ANNULAR CALCIFICATION 22 WOBBLE, WOBBLE – A PARKINSON’S DISEASE MIMICKER 23 DELAYED REACTION AND ACUTE INTERSTITIAL NEPHRITIS INDUCED BY PIPERACILLIN: A CASE REPORT 24 HEPATOCELLULAR CARCINOMA (HCC) OUTCOMES IN A PUBLIC HOSPITAL SETTING WITH INCREASED ACCESSIBILITY TO PROCEDURAL BASED THERAPY 25 A CASE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN THE SETTING OF CLASSIC HODGKIN LYMPHOMA, HIV, AND EBV 26 ENOXAPARIN INDUCED PITUITARY APOPLEXY –AN UNRECOGNIZED RISK! 27 PROFOUND NEUTROPENIA AS A SEQUELA OF PRIMARY EBV INFECTION 28 STEROID-INDUCED ACUTE PORPHYRIA: A RARE CASE OF UNEXPLAINED ABDOMINAL PAIN

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, Matthew Giglia, 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 132 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 3 most highly ranked abstracts presented at this year’s competition that were selected for oral presentations. An additional 22 abstracts presented as posters were selected

by judges for publication. All abstracts (3 oral and 22 poster) were presented at the Associates Meeting held at The Louisiana Cancer Research Center in New Orleans on March 6, 2020. 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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A CASE OF THYROTOXICOSIS INDUCED PERIODIC PARALYSIS R. Poudel MD, N. Sahami Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA

INTRODUCTION: Thyrotoxicosis brings to mind many different symptomatic complications. As thyroid hormones essentially effects every cell in the body, it’s important to consider some of the potentially fatal complications.

CASE: A 28 year old man with hyperthyroidism and atrial fibrillation presented with acute onset paralysis and palpitations one hour prior to arrival. He had been evaluated due to malaise, palpitations, cough, and congestion and treated with dexamethasone 80mg IM and IVF. He later awoke from sleep and was unable to move his extremities secondary to diffuse weakness. He reported noncompliance with his home medications that included levothyroxine, methimazole and atenolol. His examwas positive for a diffuse, non-nodular goiter, tachycardia with an irregularly irregular rhythm and 2/5 strength in all extremities. Relevant lab studies showed K5.00. EKG revealed atrial fibrillation, incomplete right bundle branch block and a QTc of 706 ms. Initial management included prophylthiouracil hydrocortisone , Lugol’s solution, cholestyramine, and magnesium supplementation which resolved the EKG changes, electrolyte disturbances and his symptoms by day two. He was discharged with counselling on triggering factors for periodic paralysis secondary to hyperthyroidism. DISCUSSION: Thyrotoxicosis and thyroid storm are dangerous complications of hyperthyroid states which can be life threatening. With the overall prevalence of hyperthyroidism in the U.S. at around 1.3%, it’s important to recognize and educate patients on the complications of ineffective treatment leading to acquired hypokalemic periodic paralysis. Specific signs of this acquired condition include sudden generalized weakness with preserved consciousness. The mechanism is currently not well understood but it’s proposed that thyroid hormone stimulates beta-adrenergic receptors which increase NA/K ATPase activity on skeletal muscles. This shifts potassium into cells causing hypokalemia resulting in hyperpolarization of the muscle membrane and decreased “excitability” of the muscle fibers leading to paralysis. Moreover, a hyperthyroid state also potentiates the hypokalemic action of epinephrine and insulin which also activates Na/K ATPase pump contributing further to hypokalemia. Keys to decreasing morbidity and mortality lies in the early detection of hyperthyroid induced hypokalemia with mindful correction of potassium as these patients are susceptible to rapid potassium shifts which may precipitate severe hyperkalemia.

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A CASE OF REGORAFENIB INDUCED PANCREATITIS: A RARE ADVERSE EVENT OF TYROSINE KINASE INHIBITORS P. M. S. Justiniano, MD Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA INTRODUCTION: Regorafenib is a multi-target tyrosine kinase inhibitor that may be indicated for treatment of patients with metastatic colorectal cancer, gastrointestinal stromal tumor or hepatocellular carcinoma. Acute pancreatitis is a rare adverse event of tyrosine kinase inhibitors and has been reported in 1000 U/L. Triglycerides, calcium and liver function tests were within normal limits. CT scan of the abdomen and pelvis with contrast showed pancreatic and peripancreatic edema. Treatment for acute pancreatitis was initiated with Lactated Ringers, anti-emetics and diet was advanced as tolerated. Regorafenib was discontinued and her symptoms improved on the third day of hospitalization, the patient was discharged in stable condition. DISCUSSION: Acute pancreatitis is most commonly precipitated by gallstones, alcohol use or other causes such as hypertriglyceridemia, hypercalcemia, or specific medications, which were ruled out in this patient. Regorafenib was considered the cause of this patient’s acute pancreatitis, given the close temporal relationship between the initiation of therapy while other causative factors were excluded. Per literature review, pancreatitis as a suspected adverse reaction of regorafenib in a patient with metastatic colorectal adenocarcinoma has not been previously reported. Acute pancreatitis is a potentially rare severe adverse event that may occur in patients starting therapy with tyrosine kinase inhibitors such as regorafenib.

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RESOLVING HEMI’S, INDUCING STEMI’S G. Devany MD, R. Eschete II MS3, J. Godke MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA INTRODUCTION: Post thrombolysis acute myocardial infarction (AMI) is a rare phenomenon but requires early recognition. Concern for an AMI should not delay or alter the management of acute ischemic stroke. CASE: A 78-year-old man with hypertension, hyperlipidemia, aortic valve replacement, right-sided carotid endarterectomy, and single vessel coronary artery bypass presented with a two-hour history of sudden onset left-sided weakness and left- sided facial droop. Physical exam revealed normal vital signs, a left-sided facial droop, left arm strength of 1/5 and left leg strength of 0/5. The patient’s National Institute of Health Stroke Scale score was 10. The initial Computed Tomography (CT) of the head was normal. The consulting neurologist diagnosed a small vessel distribution infarction causing pure motor deficits. Three hours post-onset, thrombolysis with tissue plasminogen activator (tPA) was initiated. Then the patient complained of chest tightness with substernal pain and he was noted to be diaphoretic and in obvious distress. An EKG showed ST elevations in leads II, III, aVF with ST depressions in leads I and aVL suggestive of posterior/inferior myocardial infarction. The consulting cardiologist confirmed the STEMI diagnosis and advised against any further anticoagulation or percutaneous coronary intervention due to tPA contraindications. The STEMI was medically treated. On the following day, a head-CT revealed a subacute infarction of the right thalamus and posterior limb of the internal capsule. DISCUSSION: Lysis of a thrombus overlying cholesterol containing atherosclerotic plaque may destabilize the plaque. This has been postulated to cause distal vessel cholesterol crystal embolization, not dissolved by thrombolytics. Patients with cerebrovascular and coronary artery disease might experience unintended plaque destabilization in the coronary vascular system following thrombolysis. Another explanation is that thrombolytics cause a disruption of an intracardiac thrombus and subsequent embolization to the distal coronary arteries. One report identified intracardiac thrombus in 26%of patients experiencing transient ischemic attacks by transesophageal echocardiography (TEE). Another study found a cardiac thrombus present in 2.7% of patients who had received tPA for an acute ischemic stroke. In both reports, the presence of intracardiac thrombus was associated with poor prognosis.

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HEMORRHAGIC BULLAE AS A PRESENTATION OF PHLEGMASIA CERULEA DOLENS WITH MAY-THURNER SYNDROME H. Bernstein BS, M. La MD, J. Tien MD, H. Shi MD, S. J. Cossich MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: May Thurner syndrome is a severe variant of venous thromboembolism (VTE) where the iliac vein is extrinsically compressed by the arterial system, vertebrae, or other bony structures. Symptoms include extremity pain, swelling, and skin discoloration and ulceration due to venous insufficiency. Phlegmasia Cerulea Dolens (PCD) is a severe complication of VTE where compartment syndrome can occur due to the swelling of the extremity. CASE: A 54-year old man with dementia and chronic kidney disease presented with bilateral lower extremity swelling and blistering. Examination revealed multiple tense fluid filled bullae in medial lower leg to the foot on his right and left lower extremities. They were primarily located in the distribution of saphenous veins. Femoral pulses were palpable, dorsalis pedis and posterior tibial pulses were only observed by Doppler ultrasound. A venous Doppler ultrasound study showed extensive occlusive thrombus in the left common femoral, superficial femoral, greater saphenous, and popliteal veins. A heparin dripwas initiated. Findings froma CT of the lower extremitywere concerning for phlegmasia dolens given extensive iliofemoral thrombosis and May-Thurner syndrome. Vascular surgery performed urgent mechanical thrombectomy and stenting of the left common iliac, external iliac, common femoral, and popliteal veins. Intravascular ultrasound (IVUS) confirmed aortic bifurcation compression on caval bifurcation as well as left common iliac vein compression between right common iliac and spine. He was discharged on apixiban. DISCUSSION: Skin findings from extensive VTE and PCD are often nonspecific. Marked swelling and cyanosis of the limb can occur. More often, techniques such as ultrasonography are performed to evaluate venous status. We demonstrate one of the few cases where acute on chronic VTE, including blockage of a large proximal vein, led to formation of large bullae and blistering. We hypothesized that these findings resulted from a change in venous return due to interstitial fluid hydrostatic pressure which lead to separation of epidermal cells. The treatment strategy initially involves anticoagulation, then subsequent angioplasty and stenting if applicable. Quick relief of the obstruction is key to avoiding future limb amputation.

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IT’S NOT ALWAYS TUBERCULOSIS! TREE-IN-BUD OPACITIES LEADING TO A DIAGNOSIS OF PULMONARY SARCOID J. Hong BA, J. Spraglin MD, H. Shi MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: The “tree-in-bud” sign can be commonly caused by respiratory infections including that of mycobacterial, bacterial, and viral causes. The pattern of the tree correlates to an intralobular inflammatory bronchiole and the bud correlates to inflammatory filling in alveolar ducts. Pulmonary sarcoid can show nodules in a perilymphatic distribution, but not in this particular appearance. Thus, a high degree of suspicion is required to proceed to invasive testing such as bronchoscopy, especially in a mycobacterial tuberculosis rule-out. CASE: A 27-year-old homeless man with Brugada syndrome and implanted cardioverter defibrillator initially presented for acute onset of chest pain and cough for three days. EKG showed normal sinus rhythm with no signs of ischemia. His ICD was interrogated with no events evident. Labs showed troponin Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29

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