American College of Physicians Abstract Submissions 2013 Associate Research Papers

American College of Physicians
Abstract Submissions 2013
Associate Research Papers
Table of Contents
Podium Presentations 13
Changes in Functional Status Between 3 and 12 Months After Intracerebral Hemorrhage Are
Common: A Prospective Cohort
rVEGF164b, a Novel Anti-Angiogenic VEGF-A Isoform: A Potential Therapeutic Option for Ulcerative
A Limited Intervention to Improve Physician Handoffs in an Academic Medical Center
Hospitalizations per Lupus Year: A Measure of Cumulative Disease Impact in Systemic Lupus
Impact of the 2008 USPSTF Recommendation on PSA Screening in Elderly Men
Hypocalcemia with Denosumab – Is it worth the spasm?
Weight Loss in Subclinical Hyperthyroidism 22
Haemophilus Species Bacteremia in Adults in the 21st Century: Review of 45 Episodes over 11-Year
Period in a Large Community Teaching Hospital. 23
Evaluating Quality of Care for Hospitalized Patients with Community Acquired Pneumonia at the
San Juan City Hospital, Puerto Rico 24
Poster Finalists 25
Mineral and bone disorders in end-stage kidney disease patients on hemodialysis. Integral
attention center for renal patients. Caja de Seguro Social. Colon, Panama. June-December 2012.
CHILE- POSTER FINALIST - RESEARCH Luis Alejandro Toro Cabrera, MD 27
Design and validation of a clinical prediction rule for etiology identification in patients with fever of
unknown origin 27
Creating Inpatient Clinics, the Future of Inpatient Medicine. 28
Essential Thrombocythemia (ET) and Polycythemia Vera (PV) Symptom Burden: Phenotypic Cluster
Analysis Among an international Sample of 1,141 Persons with ET and PV 29
The Provider Approval Queue and Patient Diagnostic Data: How Residents Communicate Important
Patient Information
LOX-1-A novel marker of cellular aging?
The efficacy and biocompatibility of a novel polymer-based solution in a rodent model of peritoneal
Improving the Communication of Patient Severity During Housestaff Nightly Handoffs
Burdensome Health Care Costs Among Young Adults in the United States 2010-2012
Plasma Renin Activity as a Biomarker for Mortality in Blood Pressure Extremes
The Effect of Attending Discontinuity on Quality of Care at a University-based Internal Medicine
Program 38
Clinical Characteristics, Bone Mineral Density and Non-Vertebral Osteoporotic Fracture Outcomes
Among Post-menopausal U.S. South Asian Women 39
Chapter Winning Abstract 40
Malignant Natural History Of Patients With Degenerative Mitral Stenosis: Biological Predictors Of
Survival In A Cohort of 1004 Patients
Chapter Winning Abstract - Comprehensive Hemodynamic Comparison and Frequency of Patient
Prosthesis Mismatch between the St. Jude Medical Trifecta and Epic Bioprosthetic Aortic Valves
Prognostic Indices for Older Adults: A Systematic Review
Effect of a Policy on the Appropriate Use of Copy and Paste in an Electronic Medical Record at an
Academic Community-Based Teaching Hospital
Risk of Endocarditis in Patients with Methicillin-resistant Staphylococcus aureus Bacteremia and
Severe Sepsis
Effect of impaired lung function on mortality among US adults with metabolic syndrome
Improvement of Osteoporotic Bone Quality Through Regulation of Osteoblast Activity and Wnt/ßcatenin Signaling Using NELL-1
What is the Optimal Treatment Regimen for Latent Tuberculosis? A Bayesian Network MetaAnalysis of all Randomized Controlled Trials
Do the current CMS requirements regarding inpatient hospital pneumococcal vaccine
administration promote over-vaccination of the same patient population?
Chapter Winner - Associates Basic Science Research Project
Methicillin-Resistant Staphylococcus aureus Increases the Need for Amputation in Foot
Osteomyelitis: Results from The Bone and Joint Infection Program at University of Louisville
Death Rates due to Pulmonary Embolism in the State of Georgia 52
Inhibition of miRNA-375 reduces the palmitate-induced apoptosis in enteric neurons. 53
Improving the Documentation and Interventions of Obesity in a Resident Primary Care Clinic
Chapter Winning Abstract
MOPED: Morbid Obesity Pedal Edema and Dyspnea: An emerging syndrome commonly
misdiagnosed as Heart Failure 57
Chemotherapy dosing for obese breast cancer patients: should we be cautious? 58
The effect of Proton Pump Inhibitor on Blood pressure parameters among chest pain patients
presenting to the Emergency Department (ED). 59
Changing Internal Medicine Residency: Residents’ Perspective on an Alternative 4:1 Scheduling
Approach. 61
Chapter Winning Abstract The Impact of Medication Reconciliation Initiative on Hospital
Expedited Diagnosis Units : A paradigm shift in hospital practice?
Association of Body-Mass Index and Split Bowel Preparation Quality.
The Effect of establishing evidence based guidelines for COPD
Intrapulmonary Shunt Is A Potentially Unrecognized Cause Of Ischemic Stroke And Transient
Ischemic Attack 66
The hyperuricemia causing Q141K mutation of ABCG2 uric acid transporter leads to improper
protein folding and ER associated protein degradation that can be rescued by the small molecule
corrector VRT--325 67
Implementation of a protocol for ABG use increases the diagnostic yield while reducing
unnecessary tests 69
Trends in Cancer Survivorship Care- Lessons from a large Institution based Cancer Center
Chapter Winning Abstract -- Outcomes of Inpatient-To-Outpatient Suboxone Therapy for Heroin
Addiction 71
Predicting Readmission within 30 days of Discharge after CHF and Pneumonia: A Community
Hospital Experience
Circulating microRNAs are associated with Paroxysmal or Persistent Atrial Fibrillation
Predictors of Relapse in Clostridium difficile Associated Diarrhea (CDAD)
Psychological Stress Management with Increased Physical Activity: A Study in Internal Medicine
Resident Physicians in Training
First Door-to-Balloon Time (1stD2B): Improving Door-to-Balloon Time in Patients Transferred for
Primary Percutaneous Intervention.
Patient Centered Medical Home (PCMH) in Residency Programs
Vamcomycin MIC as a Predictor of Infective Endocarditis in Patients with MRSA Bacteremia 79
Procalcitonin as a valuable marker to detect bacterial infection in ESRD patients
The Prognostic Value of Additional Malignant Lesions Detected by Magnetic Resonance Imaging
versus Mammography
Can We Use IOP Asymmetry As a Glaucoma Screening Tool 84
Association of Body Mass Index and Colon Cancer 85
Malpractice Claims of Resident Physicians in the United States
Management of Chronic Pain in an Academic Internal Medicine Clinic
The Role of Positron Emission Tomography - Computed Tomography (PET/CT) in the Prognosis of
Patients with Non Small Cell Lung Cancer (NSCLC) 88
Spontaneous Coronary Artery Disease and Fibromuscular Dysplasia--A Prospective Consecutive
Series with Extracoronary Vascular Imaging 90
Impact of Obesity on ex vivo cytokine production in rheumatoid arthritis
Venous thromboembolism prophylaxis for medical patients: Implications for a standardized order
set 92
Transaminitis in Newly Arrived Refugees to Minnesota
Resident Academic Performance and Patient Outcomes During Code Blues and Rapid Responses
Are Similar Despite Implementation of New ACGME Duty Hours
Adiposity Trajectories and Global Cognitive Function in African Americans 95
Sildenafil Protects against Acute Kidney Injury and its Deleterious Cardiac effect; Possible Role of
Vascular Endothelial Growth Factor (VEGF) 96
The Modified Early Warning Score is a Useful Tool to Diagnose Hyperglycemic Emergencies and
Predict Mortality in Resource Limited Settings
Effect of a nurse transitional care team on hospital readmissions at a tertiary care center
Effects of Tiplaxtinin Eluting Stents on Vascular Remodeling in Porcine Angioplasty Model
Opioid prescription practices among internal medicine residents in ambulatory care setting 101
Clostridium Difficile Infection in Hospitalized patients with Leukemia: A Nationwide Analysis 102
Diagnostic utility of CTA chest in “PE unlikely” patients
Resource utilization in the testing of hospitalized patients with abnormal liver tests 104
The Impact of Procalcitonin Biomarker on Length of Hospitalization for Patients admitted with
The Impact of the Economic Recession in Late 2000s on Acute Myocardial Infarction Occurrence in
Different Socioeconomic Areas of New Jersey Raritan Bay Region 106
Thrombocytopenia A Risk Factor for HIV Immunological Non-Responders
Gender based differences in Abdominal Aortic Aneurysm (AAA) Rupture: A Retrospective Review
Frequency of nosocomial infections in patients receiving red cell transfusions-a single institution
Association Of Chronic Kidney Disease And Cardiovascular Morbidity Among Hospitalized Patients
With Systemic Lupus Erythematosus: Findings From A National Study
Hepatocellular carcinoma: Ethnic Disparities in Viral Etiology: The Harlem Experience
Obesity impairs the efficacy of Colon cancer treatment
NEW YORK POSTER FINALIST - RESEARCH Tichaendepi Mundangepfupfu, MD 116
Synthesis of recombinant proteins to facilitate development of a novel Staphylococcus aureus
diagnostic test.
Complete Adherence to the ACC/AHA Guidelines Equates to Improvement in Patient Outcomes
Exome sequencing identifies a novel gene causing autosomal dominant congenital obstructive
uropathy 119
Deficiencies in the Experiences and Confidence of Primary Care Residents with Regard to Airway
Extra-pulmonary Tuberculosis: A Decade of Ex perience at a Community Teaching Hospital System
in North Carolina 123
Treatment of Left Ventricular Apical Ballooning Syndrome 125
Radiation exposure from diagnostic procedures in allogeneic stem cell transplantation - how much
is acceptable?
Exposure to Fluconazole Leads to Resistant Candida Species
Temporal Relationships of Angina Symptoms in Obstructive Sleep Apnea and Acute Coronary
Syndrome 128
Anatomy of an AMA: Discharge Against Medical Advice Documentation Analysis in a Hospital
Medicine Service 129
Uric Acid directly promotes human T-cell activation 130
Chapter Winning Abstract 131
A Comparison of Plastic and Metal Biliary Stents in Patients with Malignant Biliary Obstruction from
Pancreatic Cancer. 132
Chapter Winning Abstract 133
Morning Ventilator Huddle and Time of Extubation in medical ICU 134
The Value of Clinical Prediction in Repeat Testing with Enzyme Immunoassay for Clostridium
difficile. 136
Non-receptor tyrosine kinase c-Src activity can predict anti-EGFR therapeutic response in
metastatic colorectal cancer patients.
Comparison of TIMI score and Troponin I in determining outcomes in Nonagenarians post Acute
Coronary events 139
Tuberculin Skin Test versus Interferon-Gamma-Release Assays for initial screening of health care
Short-Term Corticosteroid Use And Hyperglycemia In Hospitalized Patients 142
A multi-center study of physician knowledge of patient fall risk
IV INFILTRATION - Reducing Hospital Incidence, Increasing Patient Safety
Hidden Barriers & Possible Solutions: A Quality Improvement Project to Improve the Length of
Hospital Stay in Patients with Diabetic Foot Infections
Chapter Winning Abstract 146
The Epworth Sleepiness Scale and its correlation with the Severity of Obstructive Sleep
Apnea in the PR population
Chapter Winning Abstract Effect of Vitamin D in Critically Ill Patients 149
Chapter Winning Abstract
A Novel Approach with A Novel Product: Aerosolizing Phytobacteria for Disinfection 151
An Assessment of Coliform Bacteria in Water Sources near Appalachian Trail Shelters
within The Great Smoky Mountains National Park
Risk factors, Complications, and Mortality among Infective Endocarditis Patients at a
Tertiary Care Medical Center
Measuring the Effectiveness of the Facilitated Check-In Rounds to Find and Teach About
Diagnostic Errors, Treatment, Care Failures and Stewardship of Resources 155
Chapter Winning Abstract
The Wright Patterson Garden Clinic: An Experiential Learning and Patient Empowerment Model
toward the Prevention and Control of Diabetes
Risk Factors and Subtype Analysis for Extended Spectrum Beta-Lactamase (ESBL)
Producing Escherichia coli and Klebsiella Species with Community-Associated or
Healthcare-Associated Infection Between 2003-May 2011
Electrocardiogram Competency of Internal Medicine Residents: An Internist’s Perspective
and the Creation of an Assessment Instrument 163
Exploration of a Novel Therapeutic Target in a Murine Model of Systemic Lupus Erythematosus:
Targeting Sphingosine-1-phosphate (S1P) Receptors
Cutaneous Leishmaniasis and the Efficacy of Azoles, a Systematic Review
Choosing Wisely Vermont Edition, developing a process to implement Choosing Wisely
principals at Fletcher Allen Health Care 167
Peripheral arterial disease is associated with impaired vascular function: evaluation of
vascular endothelial function as a mechanism for compromised cardiovascular outcomes
Chapter Winning Abstract
Safety of Clopidogrel in Thoracentesis 170
Multi-anatomic versus Nasal-only Surveillance Cultures for Detection of MRSA Colonization
among Skilled Nursing Facility Residents
Podium Presentations
Changes in Functional Status Between 3 and 12 Months After Intracerebral
Hemorrhage Are Common: A Prospective Cohort
Jonathan Kleinman, MD; Ryan W. Snider, AB; Michael Mlynash, MD; Demi Thai, MD; Irina Eyngorn, MD;
Chitra Venkatasubramanian, MD; Anna Finley Caulfield, MD; & Christine A.C. Wijman, MD, PhD
Introduction: Spontaneous intracerebral hemorrhage (ICH) is the deadliest form of stroke and
associated with high mortality and morbidity. There is limited data examining changes in functional
outcomes in ICH beyond 3-months. No scoring system has been devised to identify the likelihood that an
individual patient’s functional status will change between 3- and 12-months. These data would be
immediately practical for clinicians seeing ICH patients at 3-months to provide likelihood of
improvement or worsening in the coming months. The purpose of this study was to prospectively define
the proportion of ICH patients whose modified Rankin Scale (mRS) score changed between 3- and 12months and to examine potential factors associated with improvement or worsening.
Methods: Of 166 prospectively enrolled ICH patients, 141 with both 3- and 12-month mRS score were
included. “Good” outcome was predefined as a mRS 0-3 and “poor” outcome as a mRS 4-6. Worsening
were attributed either primarily due to consequences of the ICH and the associated physical
impairment; or to a co-morbid condition; or due to recurrent ICH.
Results: Mean age was 63±17 years, median ICH volume 15cc and median admission Glasgow coma
scale score 14. At 12-months, 55% (78/141) of patients achieved a good outcome (mRS 0-3). Of those
with a poor outcome, 58% (36/63) had died. When simply dichotomized, the proportion of patients with
good outcome remained similar between 3- and 12-months (68% versus 67%); however, 45% (51/114)
of patients changed by one or more points on the mRS during this time: 34 (30%) patients improved and
17 (16%) patients worsened. Despite starting in the poor outcome group (mRS 4-5), 20% of patients
(7/35) improved by one year. A patient with a mRS of 1-3 at 3 months had a 37% chance of further
improvement by one year (95% CI: 27-49%), and a smaller (11%) chance of worsening. Worsening was
attributed primarily to the ICH in 5/19 cases (26%) and to co-morbidities in the remaining 74% of cases.
Worsening versus improvement occurred in patients who were older (p=0.006) and had a higher mRS at
3 months (p=0.03). Factors which are classically associated with ICH outcome: hematoma volume;
admission National Institutes of Health Stroke Scale score (NIHSS); and GCS were not associated with
changes in functional outcome as measured by the mRS.
Conclusions: Change in functional outcome between 3- and 12-months is common in ICH and occurs in
almost half of patients. One-third of ICH patients continue to improve and one-sixth worsen. About
one-sixth of patients with a “poor” outcome (mRS 4-5) transition to a “good” outcome during this time
period. Other than age, baseline variables that classically predict outcome are likely already accounted
for by 3 months, as they do not predict further improvement.
rVEGF164b, a Novel Anti-Angiogenic VEGF-A Isoform: A Potential Therapeutic
Option for Ulcerative Colitis
First Author: Mihir V Patel, MBBS
Introduction: Angiogenesis process of UC results in inflamed vessels that support disease progression
through recruitment of immune cells, secretion of cytokines, and increased permeability of colonic
mucosa. VEGF-A is upregulated in the sera of patients with UC and works as driving force in
inflammatory angiogenesis and increased permeability of vessels. Evidence from models of
inflammatory angiogenesis and UC identified VEGF164 (165 in humans) as the major pathological
isoform of VEGF-A.
Inhibition of VEGF-A signaling represents an important avenue for therapy. VEGF164b is an endogenous
inhibitor of VEGF-A signaling, 20 folds greater than inhibitory VEGF in the healthy colon. Structural
variability in inhibitory VEGFs impact alteration enough to compete with VEGF-A binding, and prevent
effects on barrier function, EC proliferation and migration, and cytoskeletal alterations.
Methods: Induction of TNBS colitis was by modification of the method of Morris as enema for seven
days. Viral administration of 3 daily doses at 1011 viral particles, prior to the induction of TNBS colitis and
VEGF-A isoforms were measured by ELISA at 0, 3, 10, and 21 days. Colon length to weight ratio and
myeloperoxidase activity was measured in the supernatant of colon homogenate at days 3 and 21 by
colorimetric assay. Multiple blinded scorers using criteria established for use in TNBS colitis graded
histopathology. Vessel counts were performed on IHC sections stained for blood (MECA 32) or lymphatic
vessels (VEGFR3).
Results: rVEGF164b reduced disease activity, prevented chronic inflammatory changes by decreasing
colon length to weight ratio, and decreased MPO activity. rVEGF164b significantly inhibited blood vessels
formation in TNBS treated colons but did not entirely block angiogenesis, which may be beneficial as
complete angiogenic inhibition would prevent healing after an inflammatory flair. Lymphangiogenesis
also followed the same pattern as blood vessels. Overall histopathology was improved and inhibition of
follicular aggregate formation suggested that with reduce blood vessel formation it may change
characteristics of the remaining vessels.
Discussion and Conclusion: Every disease marker we examined showed improvements proportional or
greater to the level of angiogenic blockade that rVEGF164b provided, confirming the role intestinal
microvasculature plays in initiation and propagation of inflammatory gut disorders. This is the first
report of using an endogenous inhibitor of angiogenesis as an experimental therapeutic in UC, and
shows great potential for further investigation.
Dzundza, MD
A Limited Intervention to Improve Physician Handoffs in an Academic Medical
First Author: John Dzundza, MD Wagner, Lee-Ann MD; Kon, Rachel MD; Molineux, Mike MD; Steiner, Jill
MD; Rebecca Brown; Kamilia Esfahani; Christine Oh; Tracy Vu; Georgia Kozonis; Montero, Alex MD, MPH
Department of Internal Medicine, Georgetown University
Introduction: Every year an estimated 44,000-98,000 patients die as the result of medical errors.
Suboptimal communication has been identified as the root cause of most sentinel events in hospitalized
patients. Implementation of resident duty hours has resulted in increased frequency of patient
handoffs; the latter of which has been associated with adverse patient safety events. Our study
evaluated the impact of a one-hour didactic lecture on the quality of physician handoffs as measured by
analysis of written and verbal sign-outs among internal medicine and general surgery house-staff at
Georgetown University Hospital (GUH).
Methods: Between June 2011 and January 2012, 478 written sign-outs and 492 verbal sign-outs of GUH
medicine and surgery house-staff were directly observed before and after a 1-hour didactic lecture.
Handoffs were evaluated for the presence of accepted elements of optimal patient handoff
communication (i.e. patient identifiers, code status, medical history, anticipatory guidance,
questions/read-back, etc.). Additionally, medication lists from written sign-outs were compared to
“gold standard” lists obtained from clinical information systems. Medication errors per patient were
quantified and characterized as omissions/additions and according to severity. A pre/post intervention
analysis was carried out employing Chi-square analysis for categorical data and Student t-test analysis
for linear data. Medication errors at baseline were also analyzed by provider service.
Results: Following the intervention, presence of code status and patient location on written sign-outs
increased from 15% to 28% (p=.0008) and 73% to 86% (p=.002), respectively. More complex verbal signout elements such as “if-then” and “questions/read back” statements did not improve. At baseline,
medicine house-staff had significantly fewer average medication errors per patient than did their
surgical counter-parts (2.99 vs. 6.41; p=<.0001). Mean medication errors per patient trended downward
for both medicine (2.99 to 2.42 errors per patient, p=.194) and surgery (6.41 to 5.72 errors per patient,
p=.2964) following intervention, but did not reach statistical significance.
Conclusions: Among house-staff at GUH, an academic tertiary care center, baseline quality of written
sign-out was suboptimal. Furthermore, medication errors were common, and were more frequent on
written surgical sign-outs (a novel finding). One-hour didactic intervention modestly improved some
written sign-out elements, but had no effect on more complex verbal sign-out elements, and didn’t
reduce medication errors. More robust interventions are needed to improve physician handoff quality
(i.e. implementation of computerized physician handoff tools and more intensive/interactive
educational efforts); their effect on both process and outcomes should be studied in regards to patient
safety events.
First Author: Amardeep Shrestha, MD Suraj Arora, MD Gabriel Mikhael, MD Prabhu Ram, MD Summi
Pargal, MD Asha Alex, MD
BACKGROUND: Stress ulcer prophylaxis (SUP) has been shown to decrease gastrointestinal bleeding in
critically ill patients. However, SUP has also been used in general medicine patients without any
supportive guidelines. SUP is associated with increased risk of pneumonia, clostridium difficileassociated disease, interstitial nephritis and increased medical cost. Multiple studies have demonstrated
the overuse of SUP of up to 71%. Inappropriate SUP while transfer from ICU to general floor has not
been much studied. There has been a five week survey by Leditscheke and Coombes at a tertiary
hospital in Australia which showed 81% patients continued to receive SUP from ICU to general ward,
71% of which was used inappropriately.
OBJECTIVE: Reduce the incidence of inappropriate use of stress ulcer prophylaxis during transfer out of
the ICU to general floor.
STUDY DESIGN: We initiated our Quality Improvement project using a low cost, simple intervention of
increasing awareness among the residents. We measured the incidence of inappropriate SUP over the
course of 3 months. We followed specific guidelines given by American Journal of Hospital Pharmacists,
2007. It included any one of the 3 major criteria (home medication, active GI bleed or history of
GERD/peptic ulcer disease) or any two of the minor criteria (anticoagulation with warfarin or heparin,
active sepsis with 2 of SIRS criteria, NSAID therapy including all doses of aspirin, COPD, glucocorticoid
therapy, end stage renal disease/renal transplant and cirrhosis/liver transplant), which qualified
continued SUP. We initiated our intervention by creating posters/flyers, sending emails and reminding
indications to the ICU residents, who complete the transfer medication reconciliations. Pharmacy staffs
were also involved to help remind/evaluate the need for continued SUP. We measured the incidence of
inappropriate SUP over the course of 2 months after the intervention and compared the incidences.
RESULTS: During the pre-intervention phase July-September 2012, 72 ICU transfers to general medical
service were identified. 26 (36.1%) were transferred out of the ICU without PPI. 46 were transferred
with a PPI (63.9%). SUP was used inappropriately in 19.6% of cases. Post intervention, we had 35 total
ICU transfers from March-April 2012. 13 were transferred without PPI (37%) and 22 with PPI (63%), out
of which 18% were used inappropriately. Results showed a slight decrease in inappropriate use.
CONCLUSION: Inappropriate use of SUP during transition from ICU to medical floor has been under
looked in the literature and studies. Simple interventions such as increasing the awareness among the
residents and involving the pharmacy staffs have shown some reduction in inappropriate use of SUP. A
large scale study is needed to further determine the effectiveness and cost savings potential.
Hospitalizations per Lupus Year: A Measure of Cumulative Disease Impact in
Systemic Lupus Erythematosus
First Author: Adam B Ward, DO
Purpose: There are several standardized measures of disease activity and organ damage in systemic
lupus erythematosus (SLE). However, these measures require detailed patient interviews, medical
records, and longitudinal follow-up. Such information may not be available in population based studies
but a way to define lupus activity and damage of subjects would allow for better interpretation of
results. One prior study found that multiple admissions predicted all-cause mortality in SLE. Otherwise,
the literature regarding hospitalization frequency in lupus is sparse. We hypothesized that all-cause
hospitalization in SLE patients would directly correlate with lupus activity and damage.
Methods: A cross-sectional database at the University of Chicago recorded several measures of SLE
activity and organ damage in addition to other comorbidities, medication usage, and physical well
being. Hospitalization frequency was defined as all-cause hospitalization since SLE onset divided by SLE
duration and then reported as “hospitalizations per lupus year” (HLY). Variables of interest were
compared between groups with “high HLY” (HLY greater than or equal to 1.0) and “low HLY” (HLY less
than 1.0).
Results: Of the 218 subjects included in the final analysis the median HLY was 0.31. There were several
univariate correlates of high HLY, including younger age, shorter SLE duration, lower income, lower
hemoglobin, higher C-reactive protein (CRP), renal disease, cyclophosphamide exposure and higher
prednisone dose. After multivariate analysis, only age at enrollment (p=0.02, OR 0.96, 95% CI 0.92 –
0.99), SLE duration (p=0.001, OR 0.87, 95% CI 0.80 – 0.95, respectively), and CRP (p=0.05, OR 1.03, 95%
CI 1.00 – 1.05) retained significance. In addition, erythrocyte sedimentation rate (ESR) (p=0.03, OR 1.01,
95% CI 1.00 – 1.01) and SLE damage index (p<0.001, OR 1.64, 95% CI 1.26 – 2.13) became significant.
Discussion: In this study, we are the first to examine “hospitalizations per lupus year” (HLY) as a marker
for SLE damage and activity. After adjustment for socioeconomic status, age, SLE duration and
inflammatory markers, SLE damage index revealed a strong correlation with high HLY (p<0.001). HLY
appears to be a surrogate for lupus related organ damage and can better inform the clinician on disease
status. It may also prove useful in population based studies of SLE where traditional damage indices
prove too cumbersome. HLY was shown to directly correlate with ESR and CRP, indicating higher
degrees of inflammation. This may represent greater lupus activity, despite a lack of association
between SLEDAI and HLY. Alternatively, the inflammation may represent underlying cardiovascular
disease to which SLE patients are prone.
Impact of the 2008 USPSTF Recommendation on PSA Screening in Elderly Men
First Author: Shin Yin Lee, MD Jennifer Friderici, MS Mihaela Stefan, MD Michael Rothberg, MD, MPH
Reva Kleppel, MSW Maura Brennan, MD
Prostate-specific antigen (PSA)-based prostate cancer screening is controversial due to questionable
benefit and risks of overdiagnosis. In 2008, the US Preventative Services Task Force (USPSTF)
recommended against PSA screening in men =/>75 years old. This was expanded to include men of all
ages in the 2012 guideline. Our study evaluates the impact of the 2008 recommendation on screening
frequency in elderly men. We hypothesized that screening for men aged =/>75 would decrease, but
rates in men aged 65-74 would not change.
Methods: We included men 65 years old and older with 1 or more annual physical at 15 Baystate
Medical Practice clinics between 1/1/06 and 12/31/10. They were stratified into 2 age groups: 65-74
and =/>75. Screening PSA was assumed if a result was recorded within 30 days of the appointment.
Subjects were excluded if they had a prior abnormal result (=/>4ng/mL). Overall testing patterns were
examined using Poisson regression with robust variance estimates to account for repeat visits by a given
patient. The proportion of all appointments resulting in PSA testing was calculated on a quarterly basis
for each age stratum. Using the 3rd quarter of 2008 as the center point, piecewise regression models
were built to examine immediate pre-to-post changes in testing rates, as well as difference in slopes.
Alpha was set to 0.05 for all comparisons.
Results: Of the 5204 appointments logged over the study period, 58% were in men aged <75. In men
=/>75, the estimated testing rate (TR) increased from 12.9% in the quarter preceding the
recommendations to 21.2% immediately after (RR 1.64, 95% 1.10, 2.48, p=0.02). The quarterly TR had
declined over time in the interval prior to the recommendations (RR 0.91, 95% CI 0.86, 0.97), but
stabilized afterwards (RR 1.02, 95% CI 0.97, 1.08, p-value for test of equal slopes=0.006). Similar, but
less pronounced trends were seen in men aged 65-74; the TR increased from 40.1% in the quarter
immediately preceding the recommendations to 43.3% after (RR 1.08, 95% CI 0.86, 1.35). The quarterly
TR declined before the guidelines (RR 0.96, 95% CI 0.93, 0.99), but increased afterwards (RR 1.07, 95% CI
1.04, 1.10, p-value for difference in slopes<0.001).
Conclusion: The 2008 recommendation did not reduce PSA testing rates in men aged =/>75 in this
study; rather, testing patterns were similar to the younger (65-74 year old) control group. Reasons for
guideline failure warrant further study.
Hypocalcemia with Denosumab – Is it worth the spasm?
First Author: Sunita Sharma, MD, PhD William Newman, MD, FACP
Introduction: A variable incidence of hypocalcemia has been reported in clinical trials with denosumab
(5.5-13%) as compared to commonly used bisphosphonate, zoledronic acid (3.4-6%). Denosumab, a
monoclonal antibody, is increasingly being used for treatment of postmenopausal osteoporosis and
cancer skeletal related events (SRE). Therefore, in the present research, we studied the extent of
hypocalcemia with denosumab as compared to zoledronic acid in a community hospital setting.
Methods: We retrospectively reviewed the medical records of patients who received either denosumab
or zoledronic acid from June 2010 to December 2011 at Sanford Health, Fargo. Laboratory data was
obtained for a maximum of 3 times pre-injection and 3 times post-injection within a one-year period.
The post-injection period up to 3 months was reviewed for any adverse effects. The medication list was
reviewed and the problem list on the electronic medical record was used to obtain co-morbidity data
from which the Charlson Morbidity Index was calculated. The data are presented as means with
standard deviations for continuous variables and percent with 95% confidence intervals for binomial
variables. SAS 9.2 and R 2.13.1 were used for all statistical calculations.
Results: Final review included 151 patients who received either zoledronic acid (n=100) or denosumab
(n=51). Patients who did not have calcium levels drawn post-injection were excluded. Baseline
characteristics including age, gender, Charlson Comorbidity Index median and medication use were
similar between the two groups. Percentage of patients developing albumin corrected hypocalcemia
was higher in the patient group receiving denosumab (15.6%) as compared to zoledronic acid (8.5%), but
this did not reach statistical significance (P = 0.17). The frequency of hypocalcemia was statistically
significant (p<0.05) following denosumab injection but not with zoledronic acid (p=0.26). One patient
receiving denosumab was hospitalized with hypocalemic tetany.
In our study, we found that there is hypocalcemia is roughly twice as high in the denosumab group with
one patient admitted with symptomatic hypocalcemia. Even though rare, the possibility of life
threatening hypocalcemia exists with these agents and physicians should monitor serum calcium levels
closely and ensure adequate serum calcium and vitamin D levels prior to administration of denosumab.
Weight Loss in Subclinical Hyperthyroidism
Rohit Kedia,DO Second Author:Thomas Koroscil,MD,PhD Third Author:Alicia Lowes,DO
FourthAuthor:SarahFackler,MD Fifth Author:Ronald Markert PhD
Introduction: The association of thyroid hormone concentrations and weight loss is unclear. Patients
with thyroid carcinoma are treated with total thyroidectomy and TH doses to suppress the TSH below
the normal range. Patients who have undergone thyroidectomy with benign disease are treated with
replacement dose of TH to maintain the TSH within the normal limits. We compared weight change
between thyroid cancer patients (total thyroidectomy + suppressed TSH) to patients with benign thyroid
disease (total thyroidectomy + normal TSH).
Methods: In a retrospective study the medical records identified patients who had had a thyroidectomy
for thyroid cancer or for benign thyroid disease. Two hundred and ninety-one patients were included in
the study. Weights were recorded prior to surgery and one, two, and three years post-surgery and TSH
levels were measured at similar intervals. The independent samples t test was used to compare the
cancer and benign groups for absolute and percent change from initial weight and for TSH
concentrations at years one through three.
Results: Of the 291 patients, 147 were in the cancer group and 144 in the benign group. For weight
comparisons the cancer and benign groups had sample sizes of 132 and 113, 107 and 74, and 61 and 30
at year one, two, and three, respectively. The two groups did not differ in pre-surgery weight (cancer =
185.9±42.3 lbs, non-cancer = 186.6±44.1 lbs; p = 0.90). At year one the weight gain in the cancer group
was .41±12.4 lbs and in the benign group was 4.2±12.4 lbs (p = 0.018) [percent gain = .42% vs. 2.17%; p =
0.034]. At year two weight gain in the cancer group was 1.02±16.9 lbs and in the non-cancer group was
5.12±14.5 lbs (p = 0.092) [percent gain = 1.04% vs. 2.73%; p = 0.20]. At year three weight gain in the
cancer group was 3.90±15.3 lbs and in the non-cancer group was 6.75±23.9 lbs (p = 0.49) [percent gain =
2.4% vs. 3.84%; p = 0.56]. Average TSH between groups (cancer= .14±.16, .12±.15, .14+.20
benign=2.44±3.07, 2.87±4.41, 2.51±4.42) at year one, two and three, respectively.
Conclusions: Among patients who had had a total thyroidectomy, patients with benign thyroid disease
on maintenance T4 gained more weight in both absolute pounds as well as percent change compared to
thyroid cancer patients maintained on suppressive therapy, but the increase was only statistically
significant at one year. Excessive thyroid replacement inducing subclinical hyperthyroidism does not
result in weight loss in patients who have undergone total thyroidectomy.
Haemophilus Species Bacteremia in Adults in the 21st Century: Review of 45
Episodes over 11-Year Period in a Large Community Teaching Hospital.
First Author: Ashley L Desmett, MD (Associate) Second Author: Tiffany N Latta, DO (Associate) Third
Author: Neal Sharma, BS Fourth Author: Joseph P Myers, MD, FACP
Introduction: Haemophilus bacteremia (HB) has historically been a pediatric disease. With the advent of
conjugated Haemophilus influenzae type B pediatric vaccination, HB is rarely seen in pediatrics. HB is
occasionally seen in adults. In order to understand the current epidemiology and pathogenicity of HB in
adults, we reviewed all adult patients with HB at our 577-bed adult hospital from 2001 to 2012.
Methods: We reviewed the medical records of all adult (> 16 years) patients with Haemophilus species
bacteremia at our institution during the almost eleven-year period from January 1, 2001 to November
30, 2012 and herein report the incidence, epidemiology, source of infection, comorbid conditions,
treatment and mortality of HB for these patients.
Results: There were 45 episodes of HB during the study period. There was a mean of 4.1 episodes per
year with a range of 1-8 episodes per year. There were 20 episodes in women (44.4%) and 25 in men
(55.6%). 39 of 45 patients (86.6%) had bacteremia caused by Haemophilus influenzae and 6 of 45
patients had bacteremia caused by Haemophilus parainfluenzae. Patients' ages ranged from 20 to 91
years with a mean of 69.6 years and a median of 70 years. The eighth (11 cases = 24.4%) and ninth (13
cases = 28.9%) decades were the ages of highest occurrence. The most common source of infection was
pneumonia (31 cases = 68.9%) followed by biliary sepsis (4 cases = 8.9%), spontaneous bacteremia (3
cases = 8.9%) and skin and soft tissue infections (3 cases = 6.6%). There was one case each of
endometritis, epiglottitis, meningitis, and endocarditis. The most common comorbid conditions were
hypertension (16 cases = 35.5%), malignancy (15 cases = 33.3%), neurologic disease (12 cases = 26.6%),
congestive heart failure (8 cases = 17.7%), coronary artery disease (7 cases = 15.5%), chronic kidney
disease (7 cases = 15.5%), and diabetes mellitus (7 cases = 15.5%). Most patients had multiple comorbid
conditions. The most common initial therapy for these patients was either a fluoroquinolone or a
combination of ceftriaxone and azithromycin, reflecting our institution’s community-acquired
pneumonia treatment protocol as well as pneumonia being the most common presenting manifestation.
Six of 45 patients died for a mortality rate of 13.3%.
Conclusion: Haemophilus species bacteremia continues to occur in the adult population, is most
commonly caused by Haemophilus influenza (86.6%), is most prevalent in the 8th and 9th decades of life,
and has a significant mortality rate (13.3%) despite almost uniformly appropriate initial empiric
antimicrobial therapy. Pneumonia is the most common presenting manifestation and hypertension,
known underlying malignancy, and neurologic disease were the most common comorbid conditions.
Evaluating Quality of Care for Hospitalized Patients with Community Acquired
Pneumonia at the San Juan City Hospital, Puerto Rico
First Author: Carolina P Collazo, MD
Background: National guidelines for the management of hospitalized patients with pneumonia suggest
particular interventions that are associated with better patient outcomes. The Joint Commission and
the Centers for Medicare and Medicaid Services have developed quality indicators to help institutions to
define the quality of care in hospitalized patients with pneumonia. Reaching 100% compliance with all
quality indicators may be an unrealistic goal. However, 90% compliance is often cited as a reasonable
target. Identification of areas with poor compliance is necessary to define specific interventions for
Objective: The objective of this study was to evaluate the quality of care for hospitalized patients with
Community Acquired Pneumonia at the San Juan City Hospital in San Juan, Puerto Rico using quality
Methods: Any patient 18 years old or greater with a new pulmonary infiltrate at the time hospitalization
plus either cough, sputum production, fever, or leukocytosis were classified as Community Acquired
Pneumonia (CAP). HCAP and VAP patients were excluded. The following quality indicators were
evaluated: oxygen assessment, blood cultures obtained, antibiotics ordered in compliance with national
guidelines, appropriate antibiotic timing, and antibiotic switch from intravenous to oral within 24 hours
after meeting criteria for clinical stability.
Results: A total of 50 patients were enrolled in the study.
Appropriate antibiotic switch from intravenous to oral therapy was achieved only in 50% of the
patients. Appropriate timing of initiation of antibiotics was started in only 47% of the patients.
Appropriate antibiotic therapy was given in 80 % of the patients. Blood cultures were obtained in
approximately 76% of the patients. Adequate oxygen assessment was done in approximately 92% of the
Conclusions: In this study, oxygen assessment was the only quality indicator of the management of
community acquired pneumonia that exceeded 90% compliance. These data indicates that local
interventions should be developed to improve compliance with antibiotic switch therapy and antibiotic
timing. Since optimal switch therapy is associated with decreased length of hospital stay, there is a great
opportunity to improve clinical outcomes and reduce costs of care of hospitalized patients with CAP. The
CAP patients in our study had twice the mortality rate compared to the data worldwide. Improving
quality of care in this group of patients could reduce mortality rates. The mayor contributor fact being
that 9 out of 50 patients evaluated in the study fulfill the IDSA-ATS criteria for HCAP instead, these cases
were admitted and treated as CAP. This emphasizes the importance of early identification, correct
diagnosis, and proper initial therapy.
Poster Finalists
Mineral and bone disorders in end-stage kidney disease patients on hemodialysis.
Integral attention center for renal patients. Caja de Seguro Social. Colon, Panama.
June-December 2012.
Joel Moreno-Ríos Alejandra Loban Sergio Bolaños
Background. Chronic kidney disease (CKD) is a public health problem that affects 5 to 10% of the world's
population. The alteration in the mineral and endocrine function of the CKD is critically important in
regulation, both in the initial formation of bone during growth, as in structure and function during
adulthood. The aim of our study was to describe mineral and bone disorders in patients with end-stage
kidney disease on hemodialysis, who come to our integral attention center.
Methods. A cross-sectional descriptive study, involving patients with end-stage kidney disease, treated
with hemodialysis in Integral Attention Centre for Renal Patients of the Caja de Segruo Social, in Colon,
Panama, was performed from June to October of 2012. After signing an informed consent, we conduct a
review of clinical records, to collect data in epidemiology, biochemical parameters, and treatment used.
Results. 48 patients were enrolled, of whom 61% were men, and 35% were above 60 years. Among the
personal background 89% were suffering from hypertension and 27% of diabetes mellitus. The average
values of biochemical parameters were: parathormone 494 pg/mL, corrected serum calcium 8.89 mg/dL,
serum phosphorus 5.1 mg/dL, and alkaline phosphatase 140 U/dL. Treatments used for mineral and
bone disorders were paricalcitol (vitamin D) in 58%, phosphorus binders in 54% and calcium
supplements at 31%.
Conclusions. In our study, hypertension was the most frequent personal background of patients with
end-stage kidney disease. Data suggestive of mineral and bone disorders were found in more than 85%
of the patients studied. The most widely used treatment was the paricalcitol, followed by phosphorus
binders and, lastly, calcium supplements.
Keywords: end-stage kidney disease, mineral and bone disorders, hemodialysis.
Design and validation of a clinical prediction rule for etiology identification in
patients with fever of unknown origin
Luis Toro, MD (Associate). Pablo Gaete, MD. Maria Paz Salinas, MS. Alvaro Tala, MS. Department of
Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile.
Introduction: Fever of unknown origin (FUO) is an entity of difficult diagnosis, due to the several
etiologies that may cause it. Actually, there is limited evidence to help doing an efficient etiologic study.
The objective of this study is to design a clinical prediction rule (CPR) for identifying infectious disease in
patients with classic FUO.
Patients and Methods: Data was obtained from a historical cohort of patients admitted in our Internal
Medicine unit, between 2006 and 2011, for study of classic FUO, defined by Durack criteria (Curr Clin
Top Infect Dis 1991). Demographic, clinical and laboratory variables, plus discharge diagnosis were
analyzed. To derivate CPR, we analysed potential predictors in a logistic regression model. The variables
that resulted statistically significant as predictors were included in the CPR and a Receiver Operating
Characteristic (ROC) analysis was made to determinate the quality of the rule. To validate CPR, we
analysed the prediction capacity of the CPR in a different group of patients, using ROC analysis.
Results: Of a total of 10084 patients admitted in the Internal Medicine Unit, 241 fulfilled diagnostic
criteria. Age: 42.9±17.0 years. Male: 58.3%. Cause of FUO: Infectious: 39.6%. Autoimmune: 16.3%.
Cancer: 18.5%. Miscellaneous: 7.0%. Unknown: 18.6%. 121 patients were included for the design of the
CPR and 120 patients were included for the validation stage. Statistical analysis showed only 4 significant
predictors of infectious etiology: Serum procalcitonin (PCT; OR: 5,1), fever of less than 1 month (OR:
2,7), presence of chills (OR: 2,6) and evidence of palpable lymph nodes (OR: 1,7). The ROC curve of the
CPR had an AUC of 0.87 (p<0.001). The best cut-off point had sensibility (Se): 90% and specificity (Sp):
85%, with an accuracy of 87% (positive predictive value [PPV]: 79.6%, negative predictive value [NPV]:
1.6%). After excluding patients who had HIV as the cause of FUO, the best cut-off point had Se: 96% and
Sp: 89%, with an accuracy of 92% (PPV: 84.6%, NPV: 0.4%).
Conclusions: In patients with classic FUO, the presence of PCT > 0.1 ng/mL, fever of less than 1 month,
chills and palpable lymph nodes were associated to infectious causes. A CPR based on these variables
had a high accuracy and negative predictive value, especially in HIV negative patients, so it may be
useful specially to exclude infectious disease. This CPR should be validated with other populations to
determinate its usefulness.
Creating Inpatient Clinics, the Future of Inpatient Medicine.
First Author: Hamed Abbaszadegan, MD Second Author: Jordan Coulston, MD Third Author: Ruth Franks,
MD Fourth Author: Cheryl O'Malley, MD
Introduction: Over the last 4 years, there have been drastic changes in the way in which rounds are
conducted in academic centers. As physician order entry is becoming mainstream nationwide, residents
are often tied to their computers the entire day. This has lead to traditional walk rounding becoming
nearly extinct. Virginia Mason Medical Center has been recognized as one of the countries safest
hospitals. On a recent site visit by their internal medicine residency program director, he shared with us
their implementation of bedside flow rounds. Flow rounds is the idea of having teams work in flow
rather than batch work and round multiple times. Although longer at first, with all minds present, the
work is completed in entirety (notes, orders, discharges) before moving on to the next patient.
Methods: Utilizing guidance from the Virginia Mason Medical Center model, we set out to have 2 of 5
pilot teams at each of our program's medical centers incorporate flow rounds while the other
3 continued traditional sitting rounds. The ultimate goal was to set up an inpatient clinic. This would be
done by setting up times during which the teams would round on certain patients. Sick patients always
came first, followed by those to be discharged. Each Pilot team would not pre-round, but rather round
at together with all minds and focus on one patient. The notes would be written at the bedside, as
would orders. Nursing was also present to ask their questions related to care, rather than the traditional
method of paging the residents.
Results: After 6-8 weeks of the pilot teams rolling out the new method of flow rounds, we are seeing
that discharge orders and resident/intern notes are all being completed at earlier times. This has not
always led to earlier discharges from the hospital, but that process is under active investigation. There
have been struggles to get all teams to buy into the new rounds, as residents are anxious to type
out notes and place orders on their own after rounds. Residents are still more in favor of sitting rounds
rather than bedside rounds. We are monitoring to see if work hours are violated as well, but the data
are too preliminary at this time. The study is ongoing.
Conclusions: An inpatient clinic is a bold and innovative idea that can drastically improve patient safety.
There are still more data to be collected, and work to be done. Early indications are that
nursing communication is much improved. Residents still need to buy into the longer rounds, with the
realization that the day will be done sooner, and patient outcomes improved as well.
Essential Thrombocythemia (ET) and Polycythemia Vera (PV) Symptom Burden:
Phenotypic Cluster Analysis Among an international Sample of 1,141 Persons with
ET and PV
First Author: Robyn Emanuel, MD Additional Authors: Amylou C. Dueck, PhD, Holly L. Geyer, MD, JeanJacques Kiladjian, MD, PhD, Stefanie Slot BSc, Sonja Zweegman, MD PhD4, Peter AW te Boekhorst, MD
PhD5, Suzan Commandeur MSc6, Harry Schouten, MD, Mesa, RA,
PURPOSE: Symptom burden among persons with ET and PV can adversely affect quality of life.
Additionally, considerable symptom heterogeneity exists between patients with similar disease subtype.
No studies to date have empirically evaluated whether disease characteristics can be grouped in related
symptom clusters.
METHODS: Using the Myeloproliferative Neoplasm Assessment Form (MPN-SAF) (Blood 2011;118:401408) given in conjunction with the Brief Fatigue Inventory (Cancer 1999;85:1186-1196), data regarding
disease burden was collected from an international cohort of MPN patients. Symptom cluster
development was based on r-squared in hierarchical clustering using Ward linkage. ANOVA and chisquared tests were used for comparisons between clusters.
RESULTS: Subject Demographic and Disease Characteristics: Data from 1,141 subjects with PV (N=519)
and ET (N=622) was prospectively collected (Chinese 236, French 305, German 45, Italian 114, Dutch
191, English 56, Spanish 109, Swedish 85). Age (mean 59, range, 26–87) and gender (54% F) were typical
of this disease. Five clusters were selected to represent the whole. Frequencies of prior bleeding, spleen
size, anemia, presence of any lab abnormality, language, gender, and MPN type varied significantly
between clusters (P<0.05).
Cluster 1: The “Reduced Symptom” Profile (n=421 (37%; 60% ET, 40% PV) The largest cluster, subjects
had increased sexual difficulties and fatigue. There was a slightly higher proportion of subjects with ET
(60%) versus PV. Few lab abnormalities (28% prevalence) and less prior bleeding (3%) were present.
Spleen size was smallest of any clusters (1 cm below costal margin).
Cluster 2: The “Fatigue-dominant” Group (n=286 (25%; 56% ET, 44% PV)). Subjects in this cluster were
predominantly female and had relatively few laboratory abnormalities (19%). Complaints are
characterized by high severity of fatigue compared to end-organ symptoms. Symptom emphasis
included fatigue, QOL and insomnia with moderate end-organ complaints.
Cluster 3: The “End-Organ Complaints” Group (n=210 (18%; 49% ET, 51% PV)). Male predominant
(56%), subjects had mainly macro-vascular symptom complaints including sexual difficulties, insomnia,
and overall QOL, with few microvascular related symptoms (low itching/night sweats).
Cluster 4: ”Cognitive Complaints” Cluster (n=110 (10%; 53% ET, 47% PV)). The smallest cluster and
female predominant (64%), main complaints include fatigue, insomnia, concentration, numbness, and
sad mood.
Cluster 5: The “Highly Symptomatic” Cluster (n=114 (10%; 44% ET, 56% PV)). Subjects had many
cognitive complaints and symptoms correlated with severe micro-vascular abnormalities (pruritus) and
or splenomegaly. This cluster had the largest spleen sizes (mean 3 cm), the highest prevalence of prior
thrombosis (29%), and frequency of lab abnormalities (43%).
CONCLUSION: This analysis offers new means of evaluating persons with PV and ET utilizing symptom
clusters. Laboratory and physical abnormalities differed significantly between symptom clusters
indicating that our groupings likely result from biological alterations present in specific disease
phenotypes. Future studies should investigate correlations between clusters' prognosis and genotype.
The Provider Approval Queue and Patient Diagnostic Data: How Residents
Communicate Important Patient Information
Jonathan A. Olsen, D.O. Banner Good Samaritan Medical Center, Department of Internal Medicine,
Phoenix, AZ; Jayne Peterson, M.D. Banner Good Samaritan Medical Center Department of Internal
Medicine, Phoenix, AZ
Introduction: The Internal Medicine Center at Banner Good Samaritan Medical Center serves as the
primary continuity clinic site for 60 Categorical Internal Medicine and Medicine-Pediatric residents. The
residents utilize the Provider Approval Queue (PAQ) in the electronic health record to review patient
diagnostic information, consultation reports and to notify patients of results. It is the expectation of
every resident to review their and their partner’s PAQ each time they are in clinic and that they
communicate important diagnostic results to their patients with a letter or phone call in addition to
updating the chart. While attempts have been made to standardize this process with resident clinic
partners it was not known how residents process these data, if patients were receiving results, and how
the practice partner was updated about their own patients.
Methods: A survey was distributed to all residents that have an outpatient clinic panel reviewing key
areas including frequency the PAQ is checked, how residents communicate with their partners,
procedure for updating diagnostic information received, and how residents communicate information to
patients. 58 residents were included which included 18 Internal Medicine Pediatric and 40 Internal
Medicine residents. A response rate of 48% was achieved. This survey was repeated 6 months later
with a response rate of 41%. In addition, a chart audit was performed which included a random review
of 10 residents and 5 patients randomly selected from their panel to determine compliance of proper
chart updates of important diagnostic information.
Results: Initially, when reviewing new imaging or procedure results for patients; 58% of residents
accepted the task in the PAQ without updating necessary areas of the chart. When asked how often
residents communicate important patient information to their practice partner 65% responded, "as
needed". Six months later, 50% of residents continue to leave important diagnostic information in the
PAQ without updating the chart, but communication with residents improved with only 13% of residents
not communicating with their partner at all. 100% of residents are contacted their patients regarding
important diagnostic results.
Several areas of improvement were identified as a result of this study. It was
demonstrated that important patient diagnostic information was not appropriately being communicated
to the patient's resident provider and not being updated in the patient's chart. Immediate action was
taken and a repeat survey and chart audit 6 months later demonstrated improved compliance.
Residency is a unique setting with many transitions of care where it is vitally important to appropriately
communicate important diagnostic information to the patient and other members of the healthcare
LOX-1-A novel marker of cellular aging?
First Author: Sadip Pant, MBBS Coauthors: Abhishek Deshmukh, MD Xianwei Wang, PhD, Magomed
Khaidakov,PhD, JL Mehta, MD, PhD
Background: Lectin-like oxidized low-density lipoprotein (LOX-1) is one of the most
important receptors for binding and uptake of ox-LDL in endothelial cells, vascular smooth
muscle cells and cardiomyocytes. Previous studies have shown that LOX-1 plays an important
role in atherosclerosis, and cardiac remodeling following chronic ischemia. The objective of this
study was to analyze LOX-1 expression in the senescent cardiac fibroblasts in relation to aging.
Methods: Fibroblasts were isolated from the hearts of 8-week-old C57BL/6 mice and cultured
for up to 30 passages. Experiments were performed in fibroblasts passages 3 and 30 (referred to
as P3 and P30 cells). For gene transfection, P30 fibroblasts were seeded in 6-well plates, and
transfected with PCI-neo plasmid with human LOX-1 cDNA (h-LOX-1) or PCI-neo empty
plasmid (vector).
Results: LOX-1 expression was significantly decreased in senescent cardiac fibroblasts (passage
30 vs. 3 cells), concomitantly with significant changes in morphology (larger size), low
proliferation ability, high potential to develop apoptosis and a disorganized cytoskeleton. Forced
up-regulation of h-LOX-1 into the aged cardiac fibroblasts promoted F-actin reorganization and
the expression of CDC42 and p70 S6 kinase, two important regulators for cytoskeleton
organization and cell morphology. The expression of anti-apoptotic gene Bcl2 was lower, and
that of pro-apoptotic gene Bax higher in P30 fibroblasts, and transfection of P30 fibroblasts with
LOX-1 significantly enhanced their proliferation potential and restored the expression of related
genes (Mdm2 and phospho-Akt), but did not affect the expression of aging maker FOXO-1.
Conclusion: These findings suggest that LOX-1 contributes to the process of cellular
senescence and may be viewed as a new aging maker.
The efficacy and biocompatibility of a novel polymer-based solution in a rodent
model of peritoneal dialysis
Asher A. Mendelson, Qiunong Guan, Irina Chafeeva, Gerald da Roza, Jayachandran N. Kizhakkedathu,
and Caigan Du
Background: Peritoneal dialysis (PD) is an effective treatment of renal dysfunction, but is limited by the
lack of biocompatibility of conventional PD solutions. The present study tested the efficacy and
biocompatibility of a novel polymer as a primary osmotic agent in acute PD.
Materials and Methods: Sprague-Dawley rats were used as a preclinical model of acute PD. Peritoneal
injury and cellular infiltration were determined by both histology and flow cytometric analysis.
Results. Here we showed that intraperitoneal administration of polymer solutions significantly induced
fluid and waste removal in a concentration-dependent manner. As compared to conventional PD
solution (Dianeal™ 2.5%), polymer solutions at the concentration of 15% removed more fluid, and at
both 7.5% and 15% removed more urea, indicated by the higher amount of net urea in the effluents and
higher urea clearance rates. Histological examination indicated that the peritoneal membrane injury and
polymorphonuclear infiltrates in rats with polymer solutions was milder than those with conventional
PD solution. These observations were further confirmed by the presence of fewer neutrophils and
peritoneal mesothelial cells in the recovered polymer solutions. In vitro, more cultured human
peritoneal mesothelial cells survived following exposure to polymer solutions versus conventional PD
solution which induced cytoplasmic vacuolation and cell necrosis.
Conclusion. Our data indicate that polymer solution is superior to conventional glucose-based PD
solution in peritoneal tolerance and can achieve effective removal of fluid and urea. This supports the
potential use of this polymer as an novel osmotic agent in PD solutions.
Improving the Communication of Patient Severity During Housestaff Nightly
Daniel E Ling MD, Yas Sanaiha MS2, Michael Pfeffer MD FACP. Department of Internal Medicine, David
Geffen School of Medicine, UCLA, Los Angeles, CA
Introduction: The average Internal Medicine intern rotating through the inpatient wards performs over
300 handoffs a month, a number that will continue to increase in tandem with duty-hour limitations.
Very few Housestaff undergo substantive formal training on how to perform handoffs, yet handoffs
have been shown to be an important contributor to errors and morbidity. Furthermore, large-scale
studies on current performance and best practices are lacking. This study suggests that the use of a
simple measure of subjective severity can improve communication and help covering residents prioritize
higher acuity patients.
Methods: Handoffs from the primary team to the night float intern on the inpatient medicine wards
were observed over two separate two-month periods at Ronald Reagan UCLA Medical Center. Between
these periods, an intervention was performed where interns added to their written signouts a subjective
severity score from 1-4 for each patient, based on their concern for the patient’s clinical stability
overnight (with 4 being most concerned); no further ranking instructions were given. Data were
collected weekly and included perceived patient severity by both the primary team and night float as
well as duration of each team’s signout. The primary endpoints were compliance, degree of
correspondence between severity scores, and time spent on handoffs per patient. Additionally, surveys
were conducted to assess the satisfaction of night float with the signout process, and outcomes
including unit transfers, codes, and mortality were observed. Data were analyzed using unpaired t-tests
and multivariate regressions.
Results: A high level of compliance (>80%) with the intervention was achieved and maintained with only
a monthly email reminder. Correlation between subjective perceptions of patient stability improved
markedly with the intervention (percentage of scores matched 45.5% vs. 70.5%, p<0.001). Additionally,
while the average duration of signout time per team was unchanged, regression analysis showed that
the distribution of time became more weighted towards those patients considered by their primary
teams to be less stable. Satisfaction with handoffs trended towards a positive effect but was not
statistically significant. Outcomes such as incidence of unit transfers and codes occurred too rarely to be
adequately analyzed.
Conclusions: A relatively simple and low-cost intervention was implemented to enhance the
communication between the primary team and overnight covering intern. Results showed improved
efficiency and more appropriate allocation of time, with more attention devoted to higher acuity
patients. This was most likely due to improvement in the shared understanding of who these concerning
patients actually were. Additional data will need to be collected on handoff satisfaction to assess
whether the positive trends seen are indeed significant.
Burdensome Health Care Costs Among Young Adults in the United States 20102012
Ilana Richman, MD; Mollyann Brodie, PhD
Introduction: In recent years, rising health care costs and increased cost sharing have resulted in
significant medical expenses for many Americans. Younger adults, with lower rates of health insurance
coverage and lower incomes, may have particular difficulty affording medical care. The goal of this study
was to describe the prevalence of and risk factors for burdensome health care costs among younger and
older Americans.
Methods: We used data from the Kaiser Family Foundation monthly health care tracking polls for 6
months between 2010 and 2012. Polls included a nationally representative sample of adults. We
excluded adults aged 65 and older as Medicare beneficiaries experience markedly different costs
compared to the nonelderly population. We defined burdensome health care costs as self-reported
difficulty paying medical bills in the past year. We used logistic regression to identify risk factors for
burdensome costs and assessed for age-risk factor interactions. For analyses comparing younger and
older adults, we compared participants ages 18-39 to those ages 40-64.
Results: Our study population included 7,243 adults. After excluding adults 65 and older, our sample
had 5,493 participants. Twenty seven percent of participants reported difficulty paying medical bills, a
prevalence that did not differ by age. Low income, lack of health insurance, and poor health were
independently associated with difficulty paying medical bills after controlling for demographic
covariates. Both younger and older adults were likely to experience burdensome health care costs at
low incomes. At moderate incomes, risk fell for older adults, but remained high for younger adults
(ORolder 1.40, 95% CI 1.12-1.75, ORyounger 2.48, 95% CI 1.73-3.57, p value for interaction 0.004). Younger
adults without insurance were at risk for burdensome costs compared to their insured counterparts (OR
2.61, 95% CI 1.96-3.47). Older adults without insurance, though, had an even higher risk (OR 3.82, 95%
CI 2.93-4.97, p value for interaction 0.037). Both older and younger adults in poor health had a more
than 2-fold increase in odds of encountering burdensome costs (ORyounger 2.31, 95% CI 1.64-3.28, ORolder
2.90, 95% CI 2.33-3.59, p value for interaction 0.22).
Conclusions: Both younger and older adults commonly report difficulty paying medical bills. Younger
adults may encounter burdensome medical costs even when earning moderate incomes. Older adults,
however, are more likely to have difficulty affording medical care when uninsured. These findings
suggest that younger and older adults experience distinct vulnerabilities and may benefit differentially
from health reform efforts intended to expand coverage and limit out of pocket expenses. Future
studies may assess whether current health care reforms have successfully eased the burden of health
care costs for different demographic groups.
Plasma Renin Activity as a Biomarker for Mortality in Blood Pressure Extremes
First Author: Emil Trevis Fernando, MD
Background: Activation of the Renin angiotensin aldosterone system is paramount to maintain
normotension in a pathologic state. Plasma renin activity (PRA) can be used as a surrogate marker for
system activity and reflect whether this mechanism is appropriately functioning to stabilize BP. Past
research has revealed mixed outcomes with regards to high BP and PRA with some studies hinting
towards no relationship and others with poor outcomes. Given this conflicting data, we sought to
evaluate PRA levels in those with BP extremes (low and high BP) and hypothesize that those patient’s
with extremes in BP, PRA as a biomarker prognosticates poor outcomes as a surrogate for hemodynamic
stress or as a mechanism for it.
Methods: We conducted a retrospective study with hypertensive subjects and measured BP and PRA
values from 01/01/06 – 12/31/09. Data on mediation usage, demographics, co morbidities, and
hospitalizations were extracted from electronic medical records. Hypertensive subjects were
categorized as low (SBP<120), normotensive (120-140), and high (<140). Effective PRA was determined
based on usage of ACEI and/or ARB and then further classified into 3 categories <0.65, 0.65-6.5, >6.5
ng/ml/hr. Crude cardiovascular and mortality event rates and adjusted cox proportional hazards
modeling were used to compare outcomes based on the 3 PRA categories.
Results: 1,629 Hypertensive subjects (260 low, 627 normotensive, 742 high) were evaluated. Greatest
mortality rates occurred in the low (11.9%) and high (9.6%) BP groups compared to the normotensive
population (6.5%). Higher PRA was associated with higher mortality rates in both the low and high BP
groups. Mortality (%) within PRA categories: <0.65, 0.65-6.5, and >6.5 were: 9.9, 13.2, 23.5 in low BP
subjects; 9.2, 10.2, 13.0 in high BP subjects whereas it was unrelated in normotensive BP subjects (7.6,
3.8, 12%).
Conclusions: With an SBP 120-140 as the reference range, in subjects with both high (>140) and low
(<120) BP, higher PRA values >6.5 appear to be associated with significantly greater mortality risks.
Whether PRA serves as a biomarker for worsened outcomes and/or as a mechanism of vascular injury
remains to be established.
The Effect of Attending Discontinuity on Quality of Care at a University-based
Internal Medicine Program
Charlie M. Wray, DO, Adarsh Sai, MD, MS, Waheed Baqai, MPH, David HT Kim, MD, Lawrence K. Loo, MD
Introduction: Studies examining the importance of continuity of care with a single physician have
demonstrated improved patient outcomes. Unfortunately, most of these studies were performed in the
outpatient, rather than the inpatient setting. With over 18 million inpatients admitted to teaching
hospitals in 2010, the impact of the attending physician continuity of care on quality outcomes has not
been explored. We hypothesized that attending physician discontinuity at a large university-based
internal medicine program may adversely affect the quality of care given to hospitalized patients.
Methods: We performed a six-month retrospective analysis of administrative data from November 2011
to April 2012. We included all adult patients =18 years old admitted to/discharged from the internal
medicine teaching service. Attendings per Patient (APP) reflect a count of each internal medicine
attending physician who oversaw the care of a patient. The primary outcome was hospital Length of
Stay (LOS), with a secondary outcome of ICU (Intensive Care Unit) transfer rate. Multivariate regression
analysis was performed for LOS with patient race, gender, Charles Combined-Age Comorbidity Index
(CCI; to adjust for severity of illness), and APP as the independent variables.
Results: Our study sample included 1,012 patients with mean ± SD age of 56.3 ± 20.5 years, 59% were
females, the majority Caucasian (55%), and mean CCI 2.0 ± 2.3. Mean ± SD LOS was 5.4 ± 6.2 days, and
81 (8%) patients were transferred to ICU during hospitalization. The mean LOS for 1, 2, 3, 4-APP was 3.2,
4.1, 5.4, and 7.0 days, respectively. CCI and APP were significantly associated with LOS after adjustment
for confounders (F = 29.2, p<0.001 for CCI and F = 12.4, p<0.001 for APP). CCI and APP were also
significantly associated with ICU transfer (F = 0.451, p = 0.013 for CCI and F = 1.067, p=0.006).
Conclusion: To our knowledge, this is the first study to examine how the number of attending physicians
per patient in a University hospital teaching service is associated with an adverse effect on the overall
inpatient LOS and subsequent transfer to the ICU. Future prospective studies should examine the
optimal duration of attending faculty rotations who oversee a ward team to optimize the balance of
teaching, quality and costs of patient care.
Clinical Characteristics, Bone Mineral Density and Non-Vertebral Osteoporotic
Fracture Outcomes Among Post-menopausal U.S. South Asian Women
Stutee Khandewal MD, Malini Chandra MS MBA, Joan C. Lo MD
Purpose: The incidence of osteoporosis is increasing across various nonwhite race/ethnic populations.
However, there are limited data pertaining to osteoporosis outcomes among postmenopausal South
Asian women residing in North America. This study examines the prevalence of risk factors for
osteoporosis and incidence of non-vertebral osteoporotic fracture among post-menopausal South Asian
(SA), Chinese and White women undergoing bone mineral density (BMD) testing within a large
healthcare organization in Northern California.
Methods: Using data from a retrospective study of women aged 50-85 years with femoral neck BMD
measured between 1997-2003, we identified a subset of women of SA race and an age-matched
subgroup of Chinese (1:5) and White (1:10) women and examined incidence rates of wrist, humerus and
hip fractures up to 10 years following the BMD scan. Clinical and demographic risk factors were
identified using health plan databases. Multivariable Cox regression analyses were conducted to
examine predictors of incident fractures.
Results: The study cohort included 449 SA, 2,245 Chinese and 4,490 White women, with an average age
of 58.4±6.1 years. The prevalence of femoral neck osteoporosis was higher among SA (8.9%) compared
to White (6.5%, p<0.05) women and tended to be lower than Chinese (11.9%, p=0.07) women. More SA
(7.1%) and White (9.6%) women had prior fracture compared to Chinese women (4.5%, p=0.02 and
p<0.001 respectively). Both SA and Chinese women had a lower prevalence of smoking compared with
White women, but SA women had a higher percentage with rheumatoid arthritis and treatment with
glucocorticoids. SA and Chinese women also had lower rates of hormone replacement therapy use
compared with White women. During a median of 8.4 years follow-up, wrist fractures incidence was
similar among SA and White women (287 and 303 per 100,000 person-years, respectively) but more
than two-fold lower among Chinese women (130 per 100,000 person-years, p<0.05). In multivariable
analyses, adjusting for differences in osteoporotic risk factors and treatment with bisphosphonate drugs
and hormone replacement therapy, lower BMD, prior fracture (adjusted HR 1.9, CI 1.2-3.0), White race
(adjusted HR 2.6, CI 1.7-4.2) and SA race (adjusted HR 2.5, CI 1.2-5.3, compared to Chinese race), were
associated with a higher relative rate of wrist fracture. Lower BMD, prior fracture (adjusted HR 1.5, CI
1.1-2.2), older age and White race (adjusted HR 1.9, CI 1.2-3.0, compared with Chinese race) but not SA
race were also associated with a higher relative rate of non-vertebral fractures.
Conclusions: Post-menopausal South Asian women differed from Chinese and White women with
respect to prevalence of femoral neck osteoporosis, certain risk factors and site of non-vertebral
osteoporotic fracture. These findings support the need for more studies examining fracture risk and
outcomes specific to SA women residing in the U.S. to inform clinical decisions relevant to fracture risk.
Chapter Winning Abstract
First Author: Janet Leung, MD Kambria M Hooper, M.Ed Jamie Tsui BS Clarence H Braddock III, MD, MPH
Lisa Shieh, MD, PhD
Title: Septris: Effect of Gameplay on Attitudes toward and Knowledge of How to Identify and Manage
Introduction: Over 13 million people worldwide have sepsis each year, and the expected mortality can
be as high as 25-50%. At the same time, sepsis states are under-recognized and undermanaged,
presenting fertile areas for quality improvement initiatives. As part of a multi-pronged approach to
sepsis treatment at Stanford Hospital, the Septris game ( was
developed. This on-line, interactive, and case-based game serves as a novel way to teach early sepsis
identification and evidence-based management strategies. This quality improvement project focused on
improving the game and creating a tool for evaluation of the effects of playing, with an initial Phase I
study involving 17 medicine residents. Following a PDSA cycle, the protocol was refined, and the Phase II
study ran with 156 medical students and new housestaff.
Description: We administered pre- and post-tests comprised of multiple-choice questions immediately
before and after playing the Septris game. The tests evaluated knowledge of how to identify sepsis
states, knowledge of how to manage septic patients, attitudes toward sepsis management, and
attitudes toward the Septris game.
The Phase I pilot ran in May 2012 using a total of 50 questions on the pre- and post-tests. The test was
subsequently refined to a 10 question pre-test and 19 question post-test as part of the Phase II trial in
June 2012.
Evaluation of the surveys from the Phase I study showed that the game was well-received by
participants, with all players finding the game enjoyable and stating they would recommend the game
to others. In the Phase II study, the retrospective self-rating of ability to identify and manage sepsis
increased from 2.1 to 3, and 2.1 to 2.8, respectively (1=poor, 5=excellent; n = 156; p < 0.001 for both).
Knowledge increased significantly (p < 0.001) from a pre-game score of 6 to a post-game score of 6.9 on
a ten question test. In evaluating the effects of the game using Kirkpatrick’s learning evaluation theory,
this study evaluated steps I-III (reaction, learning, and behavior/application), and further data is being
collected regarding steps III and IV (behavior/application, outcomes).
Conclusion: In summary, Septris is a novel, enjoyable, interactive, online, and case-based game that
significantly increases both knowledge and confidence in the identification and management of sepsis
Malignant Natural History Of Patients With Degenerative Mitral Stenosis:
Biological Predictors Of Survival In A Cohort of 1004 Patients
Gaurav Tyagi, MD; Iona Pasca, MD; Patricia Dang, DO; Reena Patel, MD; Ramdas Pai, MD;
Background: Degenerative mitral stenosis (DMS) is an increasingly common echocardiographic finding.
However, its clinical and biological behaviors are not known.
Methods: We searched our echocardiographic database from June 1995 to June 2011 to identify
patients with DMS defined as severe mitral annular calcification with extension to the leaflets,
transmitral flow acceleration with a mean diastolic gradient (MG) of at least 2 mmHg and absence of
commissural fusion. DMS was graded as mild for MG 2-5 mmHg, moderate for MG 6-8mmHg and severe
for MG >9mmHg. Of the 1,004 patients with DMS - 79% were mild, 14% were moderate and 7% were
severe. Comprehensive chart reviews were performed clinical data and mortality data was collected
using the National Death Index.
Results: Patient characteristics were as follows: Age 73 + 14, women 73%, coronary artery disease in
49%, atrial fibrillation in 28%; diabetes mellitus in 50%; chronic renal insufficiency in 37%, LV ejection
fraction 65 + 14%. Over a follow-up of 3.5+2.8 years, there were 549 deaths with 1 and 5 year survivals
of 78% and 47% respectively being slightly worse with higher DMS grades (p=0.02, see figure).
Additional univariate predictors of poor survivals included greater age (p<0.0001), atrial fibrillation (p=
0.001), renal insufficiency (p= 0.004), low LV ejection fraction (p= <0.0003), tricuspid regurgitation (p=
0.0001), and concomitant aortic stenosis (p= 0.02). Age, atrial fibrillation and tricuspid regurgitation
were independently associated with higher mortality.
Conclusion: 1)Degenerative mitral stenosis is not uncommon and seems to be a disease of elderly
women and is associated with diabetes and renal failure. 2) It is a marker of poor survival even when
mild. 3) Older age, atrial fibrillation and tricuspid regurgitation are independently associated with poorer
prognosis in DMS.
Chapter Winning Abstract - Comprehensive Hemodynamic Comparison and
Frequency of Patient Prosthesis Mismatch between the St. Jude Medical Trifecta
and Epic Bioprosthetic Aortic Valves
Ajay Yadlapati MD, Jimmy Diep MD, MaryJo Barnes RDCS, Daniel M. Bethencourt, Gabriel Vorobiof MD
Objective: This study sought to comprehensively evaluate the hemodynamic performance of a new low
profile stented pericardial tissue bioprosthesis (Trifecta, St. Jude Medical, St. Paul, MN) for aortic valve
replacement; and perform a comparison with a widely used stented bioprosthetic pericardial valve (Epic,
St. Jude Medical, St. Paul. MN) with respct to hemodynamics and incidence of patient-prosthesis
mismatch (PPM).
Background: Depending on definition, PPM has been reported to develop in a wide range of patients
following aortic valve replacement. We hypothesized that the low-profile Trifecta aortic valve would
have a lower incidence of PPM than the Epic bioprosthesis, in a real world setting.
Methods: From January 2010 to May 2012, 124 patients (33% women, mean age 73.6 ± 11.0 years) had
aortic valve replacement for aortic stenosis (93.5%) or aortic regurgitation (6.5%) at our hospital.
Prosthetic valve types used were Trifecta (n=75, 60.5%) and Epic (n=49, 39.5%). Intraoperative 3dimensional and Doppler transesophageal echocardiography (TEE) was used to evaluate hemodynamic
variables on both valves pre- and post-aortic valve replacement as well as pre-discharge.
Results: Baseline demographics were similar in both groups. Overall Doppler echocardiographic
evaluation revealed pre-operative average mean gradients (MG) of 41.9 ± 22.7 mmHg, average peak
gradients (PG) of 74.3 ± 36.3 mmHg, average effective orifice area (EOA) of 0.7 ± 0.3 cm2 and indexed
EOA (EOAI) of 0.4 ± 0.2 cm2/m2. Post-operative mean pressure gradient measurements are shown in
Table 3 and demonstrate significantly improved hemodynamic performance in favor of the Trifecta valve
at all valve sizes. Postoperative MG and EOAI demonstrate a shift upwards in the Epic hemodynamic
curve for any given valve EOA. Severe patient-prosthesis mismatch (defined as EOAI = 0.65 cm2/m2) was
more frequent in the Epic group than Trifecta group (n=11/40, 28% vs. n=4/67, 6%, p=0.0011).
Conclusions: The hemodynamic performance of the low-profile pericardial Trifecta valve is superior to
the bioprosthetic porcine Epic valve across all prosthesis sizes and resulted in low rates of severe patient
prosthesis mismatch.
Prognostic Indices for Older Adults: A Systematic Review
Lindsey C. Yourman, MD; Sei J. Lee, MD, MAS; Mara A. Schonberg, MD, MPH; Eric W. Widera, MD;
Alexander K. Smith
CONTEXT: To better target services to those who may benefit, many guidelines recommend
incorporating life expectancy into clinical decisions.
OBJECTIVE: To assess the quality and limitations of prognostic indices for mortality in older adults
through systematic review.
DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception
through November 2011. STUDY SELECTION: We included indices if they were validated and predicted
absolute risk of all-cause mortality in patients whose average age was 60 years or older. We excluded
indices that estimated only intensive care unit, disease-specific, or in-hospital mortality.
DATA EXTRACTION: For each prognostic index, we extracted data on clinical setting, potential for bias,
generalizability, and accuracy.
RESULTS: We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months
to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2
indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more
than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential
bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or
greater. Only 2 indices were independently validated by investigators who were not involved in the
index’s development.
CONCLUSION: We identified several indices for predicting overall mortality in different patient groups;
future studies need to independently test their accuracy in heterogeneous populations and their ability
to improve clinical outcomes before their widespread routine use can be recommended. To make
prognostic indices more accessible to researchers and clinicians, we created a website to be a repository
of validated geriatric prognostic indices.
Effect of a Policy on the Appropriate Use of Copy and Paste in an Electronic
Medical Record at an Academic Community-Based Teaching Hospital
Jodie Barr, DO, Desiree Gleason, DO, and Michael Morton MD FACP
Introduction: The institution of electronic medical records (EMR) has revolutionized the practice of
medicine. With increased utilization of EMRs, concern has developed regarding the use of the copy and
paste function, and its effects on the quality and accuracy of documentation. Very few studies have
evaluated the prevalence of copy and paste or the potential for risks to patient care.
Methods: After IRB review and approval, a policy was developed and adopted governing the use of
copy and paste in the EMR. Education on the policy was provided to housestaff. We conducted a
retrospective review of patient charts before and after institution of the policy. Charts were randomly
selected from a pool of records in which housestaff were responsible for patient care and EMR
documentation. Charts were excluded if they had less than two entries written by housestaff. Records
were analyzed for the prevalence of copy and paste, and each instance was rated using a simple scoring
scale (1-4) grading the potential impact to patient care. The score ranged from 1 (indicating minimal or
no risk to patient care) up to 4 (indicating severe risk to patient care).
Results: A total of 415 pre-policy charts were reviewed, which demonstrated a prevalence of copy and
paste of 62.9%. A total of 5.3% of charts had a #4 on the severity scale. The post-policy group had a total
of 345 charts reviewed with a prevalence of copy and paste of 43.2%. A total of 2.2% of charts had a #4
on the severity scale.
Conclusion: With the evolution of the EMR, the copy and paste function has improved physician
efficiency, but concern has arisen that with increased efficiency could come decreased reliability of the
information in the EMR. Our study demonstrates that the institution of a resident policy decreased the
prevalence of the use of copy and paste as well as decreasing the prevalence of those instances with
severe risk to patient care. We propose that instituting a simple policy, and educating residents about
the copy and paste function, would significantly improve patient entries in regard to reliability, as well as
decreasing errors that could cause potential patient harm.
Chowdhury, MBBS
Risk of Endocarditis in Patients with Methicillin-resistant Staphylococcus aureus
Bacteremia and Severe Sepsis
Anindita Chowdhury MD, Vinay Patel MD, Christian Woods MD, Andrew Shorr MD, MPH
Introduction: Methicillin-resistant Staphylococcus aureus(MRSA) remains an important cause of
bacteremia and often results in severe sepsis(SS) and sometimes patients progress to
endocarditis.Factors associated with the development of endocarditis remain unclear.Specifically, the
impact of both an elevated minimum inhibitory concentrations(MIC) for MRSA to vancomycin(VAN) and
severity of illness on the potential for endocarditis are uncertain.
Objectives: Our objectives were to correlate severity of illness and the MRSA MIC to VAN with the risk
of endocarditis in MRSA bacteremia with SS and to create a scoring tool to predict the risk of
Methods: We retrospectively identified(Jan 2009- Dec 2010) persons diagnosed with MRSA bacteremia
and SS.The eventual diagnosis of endocarditis served as the primary endpoint.We examined potential
confounders (demographics, comorbidities, severity of illness, infection characteristics).We employed
logistic regression to determine independent factors associated with endocarditis and created a risk
score to determine the likelihood of endocarditis. We determined the score’s screening characteristics
by calculating the area under the receiver operating characteristic curve (AUROC).
Results: The final cohort included 225 subjects and endocarditis arose in 12.4%, while an MIC of 2
µcg/ml occurred in 5.3%.We noted endocarditis in 11.3% if the MICs was < 2 µcg/ml compared to 33.3%
when the MICs=2 µcg/ml (p=0.047).Subjects in the ICU when diagnosed with bacteremia were 4.1 times
(95% CI: 1.7-10.1, p<0.001) more likely to suffer endocarditis.Four variables were independently
linked with endocarditis:ICU care, underlying CHF, primary bacteremia or infection related to an
intravascular device,and an MIC=2 µcg/ml. We assigned points in the score as follows:2 points for ICU
care;1 for the remaining 3 factors. As the total score rose from 0 to 5, the prevalence of endocarditis
climbed from 0% to 66.7%(p<0.001).The risk score AUROC equaled 0.77(95% CI:0.68-0.86).
Conclusions: Endocarditis remains a frequent complication of MRSA bacteremia and SS.Although
elevated MICs to VAN in MRSA occur rarely, they are linked to endocarditis, as is severity of illness.A
simple score based on baseline characteristics stratifies subjects as to their risk for endocarditis.
Chowdhury, MBBS
Effect of impaired lung function on mortality among US adults with metabolic
First Author: Anindita Chowdhury, MBBS Second Author: Dhaval Kumar Patel, MD. MPH
Introduction: Metabolic syndrome and its various components have been reported to be associated
with impaired pulmonary function and systemic inflammation. Data on the effect of impaired pulmonary
function on mortality among metabolic syndrome patients is inadequate.
Objective: The objective of our study was to determine the effect of impaired pulmonary function on
all-cause , cardiovascular and respiratory cause related mortality among adults with metabolic
Methods: We selected adults with metabolic syndrome, age between 18 to 75 years who were nonsmokers and had no cardiovascular or lung disease from the Third National Health and Nutrition
Examination Survey (NHANES III). All adults with Metabolic syndrome were divided into 3 groups
depending on spirometry results- normal , restrictive(FEV1/FVC>0.7 and predicted FVC<80%) or
obstructive( FEV1/FVC<0.7) pulmonary impairment. Multivariate Logistic Regression analysis adjusted
for age, sex, and ethnicity was used to compare various mortality rates among the 3 groups.
Results: Among the patients with metabolic syndrome (n=2564) the prevalence of restrictive and
obstructive lung impairment was estimated to be 10% and 11.1% respectively. Impaired lung function
was more prevalent in older population. After adjusting for age, sex and ethnicity the restrictive
pulmonary impairment was associated with higher all-cause mortality (33.0% vs 15.5%, OR= 2.08 CI:
1.52-2.84, P<0.0001), cardiovascular mortality (12.0% vs 4.7%,, OR= 2.10 CI: 1.35-3.26, P<0.0001),
respiratory cause related mortality (3.89% vs 1.0%, OR= 2.94 CI: 1.35-6.38, P=0.006) compared to adults
with normal lung function. Obstructive lung function was found to be associated with higher all-cause
mortality (42.1% vs 15.5%, OR= 1.29 CI: 1.11-1.49, P=0.0001) but not cardiovascular (13.5% vs 4.7%,
OR=1.18 CI:0.95-1.46, P=0.11) and respiratory cause related mortality (2.4% vs 1.0%, OR= 0.94 CI: 0.591.48, P=0.79) after adjusting for age, sex and ethnicity.
Conclusion: Impaired pulmonary function particularly restrictive pattern was found to be associated
with higher mortality among adults with metabolic syndrome
Clinical Implications: Screening of pulmonary function tests should be encouraged and further research
in needed to determine the efficacy of primary preventive strategies in the adults with metabolic
syndrome and impaired pulmonary function.
Improvement of Osteoporotic Bone Quality Through Regulation of Osteoblast
Activity and Wnt/ß-catenin Signaling Using NELL-1
First Author: Janette N Zara, MD Aaron W. James, MD Jia Shen, PhD Raghav Goyal, BS Greg Asatrian, BS
Xinli Zhang, MD, PhD Kang Ting, DMD Chia Soo, MD, FACS
INTRODUCTION: Osteoporosis is a common clinical condition affecting an estimated 10 million
Americans and conferring an increased risk of bone fracture. It results from an imbalance between bone
formation and bone resorption that depends on both the number of osteoblastic (OB) and osteoclastic
(OC) cells, as well as their cellular activity within the bone metabolic unit. Despite current anabolic
agents, there remains a significant lack of success clinically in building bone or preventing bone loss in
osteoporotic patients. Wnt/ß-catenin is a signaling system known to regulate bone maintenance that
has been targeted in the development of anabolic agents because of its positive effects on OB
differentiation and bone formation, and converse inhibitory effects on OC activity and bone resorption.
NELL-1 is a secreted protein that has been shown to have osteoinductive properties. This study aims to
determine whether NELL-1 can induce increased osteoinduction in human bone marrow stem cells
(hBMSCs) in vitro, in the presence or absence of osteoporosis.
METHODS: Discarded human bone marrow tissues from N=5 patients with or without osteoporosis
were digested with Type II collagenase to isolate hBMSCs. NELL-1 signaling was increased in hBMSCs via
transduction with adenoviral (Ad)-Nell-1, or Ad-GFP as control, to induce osteogenic differentiation
supplemented with osteogenic differentiation medium, ascorbic acid and ß-glycophosphate. Wnt/ßcatenin signaling was assessed at gene and protein levels at Day 2 and Day 3 using
immunohistochemistry, Western blotting, TCF/LEF1 reporter activity, and qRT-PCR. Osteogenesis was
assessed using Alizarin red staining, which detects mineralized bone nodules, at Day 11. Quantification
was done using Image J software.
RESULTS: Ad-NELL-1 transfection efficacy was confirmed by qRT-PCR which showed a 17.5 fold increase
in Nell-1 mRNA transcripts compared to control. NELL-1 treatment resulted in statistically significant
increase in Wnt/ß-catenin signaling activity quantified by gene markers Axin and Cyclin D compared to
control (p < 0.01). Western blot showed increased cytoplasmic and nuclear accumulation of ß-catenin in
hBMSCs from both osteoporotic and non-osteoporotic patients (p < 0.05). In addition, NELL-1 increased
OB differentiation of hBMSCs as shown by quantification of Alizarin red staining from both osteoporotic
and non-osteoporotic patients (p < 0.01).
CONCLUSION: NELL-1 induced greater osteogenic differentiation in hBMSCs by activating Wnt/ßcatenin signaling from both osteoporotic and non-osteoporotic patients. NELL-1 positively regulates
Wnt/ß-catenin signaling resulting in improved bone formation. It represents a potential new anabolic,
anti-resorptive therapy to prevent or treat osteoporotic bone loss. Finally, NELL-1 signaling may have a
new role in maintenance of bone with skeletal aging.
What is the Optimal Treatment Regimen for Latent Tuberculosis? A Bayesian
Network Meta-Analysis of all Randomized Controlled Trials
First Author: Elie Donath, MD Jonathan R. Schroeder, DO Bianca Sarmento, MD David Ashkin, MD
Introduction: Five treatment regimens for latent tuberculosis (TB) have been extensively studied;
presently the CDC considers the regimens of Isoniazid (INH) – 6 months, INH 9-12 months,
INH/Rifapentine and Rifampin alone to be generally equivalent. Most of the available evidence to
support one treatment regimen versus another is derived from one-to-one comparisons consisting of
either randomized controlled trials or meta-analyses. Little is known how well each of these treatment
regimens fit within the overall context of the other approved regimens for latent TB. The purpose of this
research was to use Bayesian methods to directly and indirectly compare each of these regimens to
each other simultaneously across several different outcomes of interest. This is the first network metaanalysis to pursue these aims.
Methods: Studies were extracted from a computerized literature search of MEDLINE and EMBASE. 24
randomized controlled trials consisting of the five most well studied treatment arms were identified –
INH alone, Rifampin alone, INH/Rifapentine and Rifampin/Pyrazinamide. The outcomes of interest
included mortality rate, rate of conversion from latent to active TB and all-cause withdrawal rate. Only
trials involving HIV-positive patients were included for the conversion and mortality outcomes as there
were an insufficient number of outcomes in non-immunocompromised individuals. INH 6 months and
INH 9-12 months were combined because there was minimal difference in outcomes between these two
populations (heterogeneity was evaluated by i-squared analysis). For all outcomes, non-informative
prior distributions were used and posterior distributions of treatment effects were constructed from 4
chains of 50,000 simulations. Calculation of the probability that each treatment is best was
implemented using the Bayesian Markov chain Monte Carlo method.
Results: Patients taking Rifampin were statistically significantly less likely to withdraw compared to INH
(RR 0.45, 95% CI 0.27-0.76), Rifampin/Pyrazinamide (RR 0.53, 95% CI 0.29-0.93) and placebo (RR 0.56,
95% CI 0.31-1.00). By ranking probability, Rifampin has an 87% probability of being the most likely
treatment regimen to reduce withdrawal rates. For both the mortality and conversion outcomes, none
of the treatment regimens is statistically significantly superior to any other. By ranking probability,
INH/Rifapentine has the highest probability of being the optimal regimen for reducing both mortality
and conversion. The degree of incoherence (measuring how closely the network fits together) was low
for all outcomes.
Conclusion: Rifampin alone is most likely to reduce the rate of withdrawals compared to other
treatment regimens for latent TB. Since there doesn’t seem to be any drug that definitively reduces the
risk of either conversion or mortality, the optimal regimen for latent TB may be whichever agent
individuals are most likely to comply with.
Do the current CMS requirements regarding inpatient hospital pneumococcal
vaccine administration promote over-vaccination of the same patient population?
First Author: Kelly Kynaston, DO Second Author: Mohamed Ali, MD FACCP
Introduction: Pneumococcal disease is responsible for 22,000 deaths, 445,000 hospitalizations, and 4
million illness episodes annually in the United States. These numbers can be improved with the use of
anti-pneumococcal vaccine. Current literature focuses on analyses of barriers to administration and
strategies to lessen disparities amongst unvaccinated populations. One such strategy is the requirement
by the Center for Medicare/Medicaid Services (CMS) to vaccinate all eligible patients during their
inpatient hospital stay. Because Self-Report of vaccines is unreliable, most institutions err on the side of
over administration if a patient’s vaccination status is unknown. The current AICP guidelines, however,
recommend one dose for previously unvaccinated adults age 65 and older. This extends to anyone, age
2-64 years with certain chronic comorbidities. A second dose is only indicated in those adults aged 65 or
older if the first vaccination was before 65 and 5 years or more have elapsed since first dose. This brings
up the question: Do the current CMS requirements regarding inpatient hospital pneumococcal vaccine
administration promote over-vaccination of the same patient population? In order to investigate the
hypothesis that CMS requirements would indeed promote redundancies in pneumovax administration, a
retrospective cohort study was designed.
Methods: Claims data was collected from Northside Hospital from June 2008 to November 2012. A
search was done via billing records for the charge code 678378, coding for the 23-valent polysaccharide
vaccine on formulary. The data obtained was then filtered by readmissions, so that only the patients
who had the opportunity to be revaccinated were included in the study sample. Readmission was
determined by patients that had the same medical record number but multiple account numbers in the
specified date range. Data was then imported to Microsoft access for ease of analysis.
Results: It was determined that 2943 patients had received the pneumovax administration at Northside
Hospital within that date range. When filtered by readmission, the total population sample that was
included in the study for analysis was 1402 patients. Of the 1402 patients that were both readmitted
and vaccinated, 13 patients received the vaccine twice. No patients received the vaccine three or more
times. In total, this accounts for 0.927 percent of patients.
Conclusion: With less than one percent of patients receiving duplicate vaccinations at Northside
Hospital in a 54 month range, the null hypothesis is accepted. In conclusion, the current CMS
requirements do not promote over vaccination of patients readmitted to the same hospital.
Recommendation can be made to continue current practice of revaccinating patients whose selfreported vaccination status is unknown.
Chapter Winner - Associates Basic Science Research Project
Marlow B Hernandez, DO
Methicillin-Resistant Staphylococcus aureus Increases the Need for Amputation in
Foot Osteomyelitis: Results from The Bone and Joint Infection Program at
University of Louisville
First Author: Daisy Azana,MD Co Authors: Humberto Mochizuki, Raul Vasquez, Julie Harting, Luke
Kovatch, Adrianne Ross, Chester Nava, Timothy Wiemken, Diana Christensen, and Julio Ramirez
Introduction: Methicillin-Resistant Staphylococcus aureus (MRSA) is an emerging and common
etiological agent of foot osteomyelitis with a prevalence of 15-30% in diabetic foot infections. Some
studies suggest that the need for amputation and surgical debridement increases in patients infected
with MRSA. However, the surgical rates are not well established. The objective of this study was to
assess the degree of association between MRSA infection and amputation rates in patients with foot
Methods: This was a retrospective, analytical study of patients with foot osteomyelitis managed at the
University of Louisville Hospital and the Robley Rex Veterans Affairs Medical Center in Louisville,
Kentucky from January 2009 to July 2011. Diagnosis of MRSA osteomyelitis was based on positive
microbiology from bone biopsy. Patients were classified in two groups: Group A, positive MRSA bone
culture, and Group B, no MRSA in bone cultures. Amputation was defined as either partial or total foot
removal, including minor surgery (affecting a portion of the fore, mid or hind foot) and below the knee
amputation. The following variables were collected to define host characteristics: sex, age,
comorbidities (diabetes, renal disease, peripheral vascular disease, tobacco abuse, history of prior
surgery at same site, previous osteomyelitis, and prior antibiotic treatment), and appropriateness of
antibiotic therapy. For statistical analysis, Pearson’s chi square test was performed, and p=0.05 was
considered statistically significant.
Results: From a total of 54 cases of foot osteomyelitis reviewed, 17 (32%) patients were in Group A
(positive MRSA bone culture) and 34 (68%) patients were in Group B. Host characteristics for both
groups were not statistically different except for prior antibiotic use: Group A 71% versus Group B 41%,
(p=0.04, OR 3.52- CI. 95%: 1.03-12.07). At one-year follow-up, Group A had 100% amputation rate
compared to 76% in Group B (p=0.026, RR 1.32, 95% CI: 1.1-1.59).
Conclusions: This study suggests that patients with foot osteomyelitis due to MRSA have a significantly
higher rate of amputation when compared to patients without MRSA. Clinical outcomes in patients with
foot osteomyelitis are impacted by the interaction of the host, the pathogen, and the treatment. Since
the treatment in both study groups were standardized and host characteristics were similar, the
difference in outcomes found in our study may be explained by MRSA virulence. Strategies addressing
MRSA virulence factors such as exotoxins, may improve outcomes in this population.
Death Rates due to Pulmonary Embolism in the State of Georgia
First Author: Heval Mohamed Kelli Ayman Tahan, Neil Winawer, Omar Lattouf
Pulmonary embolism (PE) is a potentially fatal disorder. As diagnostic modalities have improved over
time, it is unclear if these advances have impacted mortality. The aim of this study is to analyze the
death rate for patients with PE in Georgia.
Methods: Data from the Georgia Department of Public Health database were utilized based on ICD -9
and ICD-10 codes for PE to identify death rates from 1994-2008. Rates were calculated per 100,000
patients in Georgia. The statistical difference of gender and race were compared and graphs were
obtained to show the rate progression in the time period.
Results: The total death rate due to PE decreased from 3.4 per 100,000 persons in 1994 to 2.2 per
100,000 persons over the study period (P=0.000). A similar pattern was observed in gender with higher
death rates in females than males (p=0.004). The death rates for African-Americans were higher than for
whites in the beginning of the study period, but the difference narrowed over time and was not
statistically significant (p=0.074).
PE death rates in Georgia have steadily decreased over time however, remain higher in women. There
were no significant differences with respect to race over time. We theorize that the reduction in overall
PE mortality is likely due to the improved sensitivity of diagnostic testing, making early detection of PE
Inhibition of miRNA-375 reduces the palmitate-induced apoptosis in enteric
First Author: Shadi Sadeghi Yarandi, MD Nezami BG Jeppsson S Srinivasan S
Introduction: High fat diet and obesity are associated with irregularities of gastrointestinal tract motility
such as constipation. High fat diet has been shown to cause weight gain, decreases colon motility and
increases apoptosis in enteric neurons. MicroRNAs (miRNAs) are short non-coding RNAs that regulate
gene expression and are involved in numerous intracellular pathways. Novel therapeutic approaches
have been developed since discovery of miRNAs, using them as the target of intervention. miR-375 is
linked to pathogenesis of diabetes and metabolic syndrome due to high fat diet. We investigated the
role of this miRNA in palmitate-induced apoptosis of enteric neurons, leading to decreased GI motility
secondary to prolonged exposure to high fat diet.
Methods: Enteric neurons were cultured in the presence of palmitate (0.2-1mM) or control medium.
After exposure to palmitate for 24h, miR-375 was measured by real-time PCR. Next, enteric neurons
were treated with inhibitors of miR-375 or miRNA negative controls for 24 hours followed by palmitate
treatment (0.5mM) for 24 hours. Apoptosis was assessed by measuring cleaved caspase-3 using Western
blot analysis.
Results: Palmitate (0.5mM) induced a significant increase in expression of miR-375 (14.6 folds, P<0.001)
in enteric neurons relative to control. In the presence of miR-375 inhibitor, palmitate-induced apoptosis
in enteric neurons was significantly reduced compared to palmitate treated cells after transfection with
mir-375 inhibitor negative control (P<0.001).
Conclusion: Our findings demonstrate a role for miR-375 in mediating palmitate induced enteric
neuronal apoptosis. Inhibition of miR-375 led to increased enteric neuronal survival. miR-375 may be
future therapeutic targets in improving gastrointestinal motility in patients with obesity.
Improving the Documentation and Interventions of Obesity in a Resident Primary
Care Clinic
K Wilmot, M Prasad, J Cheeley, J Torgerson, J Shen, A Saraf, J Luke, S Patel, T Runge, S Schmidt , B
Adhyaru, N Ilksoy
PURPOSE:More than one-third of the US population is obese, as defined by a body mass index (BMI)
greater than 30. Obesity is an increasing public health problem and increases patients’ risk of diabetes,
heart disease, and certain cancers. The annual cost of obesity in Georgia is $2.4 billion, including direct
health care costs and lost productivity. The aim of this project was not only to increase obesity
documentation in our clinic, but also to increase obesity interventions.
METHODS: We utilized the quality improvement model outlined by the Institute of Healthcare
Improvement using a plan-do-study-act cycle. Residents (PGY1 - PGY3) collected data on obesity
screening rates in their clinic and implemented a test of change (TOC) aimed toward improving these
The first year was aimed at increasing BMI and obesity documentation and introduced an electronic
medical record (EMR) and BMI auto-population (TOC #1), height added to nursing triage template (TOC
#2), and provider education on documentation of obesity (TOC #3).
The second year was focused on continual improvement of obesity documentation and implementation
of obesity interventions. TOCs included an email reminder to physicians regarding obesity interventions
(TOC #4) and flyers on obesity clinic referrals (TOC #5).
RESULTS: Initial BMI documentation in our clinic was below 5% because height was not part of the
nurse’s triage template and we used paper charting. Once TOC #1 & #2 were implemented, BMI
documentation rose close to 100%. Our next TOC was focused on improving provider documentation of
obesity (TOC #3), and obesity documentation rose from 37% to 50%.
In year two, obesity documentation fell to 18% and obesity interventions were as low as 9%. TOC #4 was
enacted creating an increase in obesity documentation to 50% and then 100% in the successive month.
Similarly obesity interventions after TOC #4 increased significantly to 50% and then 100% in the
successive month.
Unfortunately, three months after TOC #4, obesity documentation and interventions dropped
significantly to 29% and 42%, respectively. To re-assess sustainability, TOCs #5 and #6 were applied and
both obesity documentation and obesity interventions increased again to 100%, but both decreased to
60% within two months.
CONCLUSIONS: Auto-population of BMI through the EMR has improved documentation and
interventions of obesity in our clinic. If obesity is listed as a separate problem, an intervention is often
proposed. Periodic reminders improve physician adherence to documentation of obesity and
interventions, but are not easily sustainable because of barriers such as time for physicians, visibility of
BMI in the EMR, and that interventions ascribed were actually attended by patients. Currently our EMR
requires documentation of patients’ BMIs greater than 35 and we will need to evaluate how this
improves future documentation and interventions.
Chapter Winning Abstract
Anti-Gliadin Antibodies Identify Celiac Patients Overlooked by Tissue Transglutaminase Antibodies
CPT Brian C. Benson, MD (Associate)1, CPT Christopher Mulder, DO (Associate)3, MAJ Jeffrey T. Laczek,
MD (Member)2
Department of Medicine and 2Gastroenterology Service, Tripler Army Medical Center, Hawaii
Gastroenterology Service, Brooke Army Medical Center
Introduction: Serologic testing is recommended as the initial screening for patients with suspected
celiac disease; positive serologic testing should be confirmed with a small bowel biopsy. The American
Gastroenterological Association recommends initial serologic testing with anti-tissue tranglutaminase
antibody (tTG) alone. At our facility, we routinely screen with a combination of tTG and anti-gliadin
antibody (AGA). We sought to test our hypothesis that using this combination rather than tTG alone
would result in more false positive tests while failing to increase identification of patients with celiac
Methods: A retrospective review was performed of all celiac serologies at Tripler Army Medical Center
between September 2008 and March 2012. For patients with positive serologic testing, small bowel
biopsy results or reasoning for deferring biopsy were investigated.
Results: During our specified time period, 2,733 patients were evaluated with a total of 5,268 AGA and
tTG antibodies. 232 patients had at least one positive or equivocal serologic screening test, including 34
tTG, 120 AGA IgA, and 119 AGA IgG. Of these 232 patients with positive screening serologies, 87 (38%)
underwent a small bowl biopsy and identified 26 patients with celiac disease. The positive predictive
value of tTG was calculated to be 100%, AGA IgA was 36%, and AGA IgG was 16%. 5 of 26 patients (20 %)
with biopsy-proven celiac disease during our specified period had a positive or equivocal AGA IgA or IgG
and a negative tTG. Of patients with at least one positive serologic screening antibody, 147 (62%) did not
undergo a small bowel biopsy.
Conclusions: While tTG has a significantly higher positive predictive value than AGA antibodies, AGA
antibodies do increase the number of patients identified with celiac disease compared with tTG alone.
Based on the results of this study, we reject our initial hypothesis. Screening with tTG in combination
with AGA appeared beneficial if the goal of serologic testing is to maximize the number of patients with
celiac disease. Close follow-up of patients with positive celiac serologies is needed to ensure that they
have the opportunity to undergo small bowl biopsy.
Disclaimer: The views expressed in this abstract/manuscript are those of the author(s) and do not reflect
the official policy or position of the Department of the Army, Department of Defense, or the US
MOPED: Morbid Obesity Pedal Edema and Dyspnea: An emerging syndrome
commonly misdiagnosed as Heart Failure
First Author: AJAY JOSEPH, MD Second Author:S Gulati Third Author: S Gupta Fourth author: R Kashinath
Fifth author: T Alyousef Sixth Author: R Kumapley
INTRODUCTION: Presence of obesity increases an individual’s risk of developing Heart Failure(HF)
according to the Framingham study (NEJM2002;347:305-13).Morbid obesity (BMI >40 kg/m2)commonly
causes dependent pedal edema (Circulation2006;113:898-913) and deconditioning resulting in
dyspnea.Jugular Venous Distension (JVD) and Paroxysmal Nocturnal Dyspnea (PND) may be difficult to
illicit in such obese patients. When these patients present with dyspnea and edema and a normal
echocardiogram, they are commonly misdiagnosed as HF with preserved EF (HF-PEF). We undertook this
study to identify morbidly obese patients with pedal edema and dyspnea with a diagnosis of HF without
other features of HF on history, exam and imaging. We hereby propose the syndrome of MOPED for
such patients and suggest that other diagnoses be entertained before labeling these patients as HF-PEF.
METHODS: Cook County Hospital is one of the largest public hospitals in the country.The Short Stay Unit
(SSU) admits majority of the patients with heart failure from the Emergency Department (ED).Via the
electronic medical record system we identified all admissions to the SSU during the months of July 2011
to December 2011.All patients with an admitting diagnosis of HF from the ED were identified.The charts
of these patients were then retrospectively reviewed for clinical signs and symptoms of HF,discharge
diagnosis of HF,BMI and echocardiographic findings.Patients with a discharge diagnosis of HF, BMI >40
kg/m2,completely normal echocardiogram, presence of dyspnea and pedal edema with absence of PND,
JVD and chest X-Ray findings of HF were classified as MOPED.
RESULTS: A total of 934 patients were admitted to the SSU from July 2011 to Dec 2011 of which 252
patients had an ED admitting diagnosis of HF; 184 (73%) patients had a discharge diagnosis of HF. Fiftynine (32%) of these 184 patients were morbidly obese and on further review MOPED was identified in
15 (25%) of these patients who had a discharge diagnosis of HF and not much supporting evidence of
the same.This amounts to 8% of all patients with HF.
CONCLUSION: About 8% of all HF patients and a significant number (25%) of morbidly obese patients
with a diagnosis of HF actually do not have enough supporting evidence of HF and have the syndrome of
MOPED, which may have other differentials as the cause of their pedal edema and dyspnea.Morbidly
obese patients pose a challenge during physical exam and imaging.About 1 in 4 morbidly obese patients
diagnosed with HF have MOPED, needing further clarification,with HF-PEF being one of the causes of the
syndrome,other causes to consider include pulmonary embolism,obesity hypoventilation,obstructive
sleep apnea,hypothyroidism or obesity itself.
Chemotherapy dosing for obese breast cancer patients: should we be cautious?
First Author: ANKIT MANGLA, MD Second Author: AJAY JOSEPH, MD Third Author: SHWETA GUPTA, MD
Fourth Author: BARBARA YIM Fifth Author: SUSAN MC DUNN, MD
INTRODUCTION: Chemotherapy dosing for the obese cancer patients has been a matter of debate for
many years. Recently the American Society of Clinical Oncology (ASCO) issued new guidelines on the
topic stating that the obese patients should be given chemotherapy per their actual weight with no dose
reduction/modification needed due to obesity. However the data supporting the statement was weak
and no large randomized trials have been done on the same so far. We studied our obese breast cancer
patients retrospectively comparing them to the non-obese patients after the issuance of the new
guidelines for the lipophilic medication Adriamycin which can cause higher toxicity with higher dose.
METHODS: John H Stroger Jr. Hospital of Cook County is one of the largest public hospitals in the
country providing service to over 200 new breast cancer patients each year with over half representing
minority populations. The ASCO guidelines on chemotherapy dosing for obese patients were reported in
April 2012. We identified all patients who received Adriamycin from May 2012 onwards from the
pharmacy database of our hospital. All charts were retrospectively screened and patients with breast
cancer were identified. A note was made of the BSA, BMI, chemotherapy doses, dose delay and adverse
effects. Patients with incomplete charts or lost to follow up were excluded.
RESULTS: A total of 162 patients were identified from the pharmacy database of which there were 74
breast cancer patients who met the inclusion criteria. Twenty-nine were obese with BMI >30 kg/m2 and
45 were not obese, of which, 22 were overweight (BMI 25-30 kg/m2) and 23 were normal weight or
underweight. Only 11 patients (38%) in the obese group had a BSA more than 2/m2, a sometimesarbitrary value used by some physicians for chemotherapy dose calculation once the BSA is higher.
Chemotherapy dose delay was seen in 6 obese patients (21%) as compared to 6 patients (13%) in the
non-obese group (n=45). There were 4 events of neutropenic sepsis, 3 of which (75%) happened in the
obese category and one in overweight category. There was one death, which happened in a morbidly
obese patient (BMI 68 kg/m2) after 4th dose of Adriamycin.
CONCLUSION: Our results indicate that caution should be exercised in dosing lipophilic chemotherapy
like Adriamycin for obese patients. About one in four patients would experience a dose delay, which
may affect the clinical outcomes and there seems to be a high incidence of sepsis and even death in this
group. Many of the obese patients may not have a very high BSA, giving a false sense of security for the
ordering physician. More randomized studies are needed to clarify this finding further and strengthen
the guidelines.
The effect of Proton Pump Inhibitor on Blood pressure parameters among chest
pain patients presenting to the Emergency Department (ED).
First Author: Affan Irfan Second Author: Tobias Reichlin Third Author: Raphael Twerenbold Fourth
Author: Karin Wildi Last Author: Christian Mueller
The effect of Proton Pump Inhibitor on Blood pressure parameters among chest pain patients
presenting to the Emergency Department (ED).
Affan Irfan, MD1,2; Tobias Reichlin, MD1,3; Raphael Twerenbold, MD1,4; Karin Wildi MD1, Christian
Mueller, MD1
Department of Cardiology, University Hospital Basel, Switzerland; 2Department of Internal Medicine,
University of Illinois Urbana-Champaign, IL, USA; 3Cardiovascular Division, Department of Medicine,
Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA. 4 Universitäres HerzZentrum Bad Krozingen, Germany
Background: Recent studies have shown that proton pump inhibitor (PPI) seem to be associated with
increased risk for adverse cardiovascular outcomes. We sought to determine whether oral PPI use has
any effect on blood pressure parameters among chest pain patients presenting to the Emergency
Department (ED).
Methods: In an observational international multicenter study, we enrolled 1240 consecutive patients
presenting with acute chest pain to the ED. Vitals, including Systolic and diastolic blood pressure (SBP
and DSP) were measured at the time of presentation to ED. The final diagnosis was adjudicated by two
independent cardiologists. Multivariate linear logistic regression was used to analyze the effect of PPI
use on blood pressure parameters and to control for other factors. A total of 268 (22%) patients had PPI
use on admission and 196 (16%) were diagnosed with acute myocardial infarction as the diagnosis for
chest pain.
Results: Patients with PPI use had significantly lower SBP and DBP vs the rest (median [InterQuartile
range] for SBP; 139 [125 - 157] vs 143 [128 - 161] mmHg, p=0.01 and DBP; 80 [69 - 89] vs 85 [76 - 95]
mmHg, p<0.001). The pulse pressure and the HR was similar in both groups (p>0.05). The significant
lower SBP and DBP was observed among patients with PPI use even when adjusted according to the
variables found significant with univariate analysis (age, BMI, hypertension, renal insufficiency, known
coronary artery disease, prior stroke, statin, ACEI and ARB use on admission), p=0.008 and p=0.028,
respectively. This significant association was also seen even when adjusted according to final diagnosis.
Limitations: Unmeasured and residual confounding factors such as diseases (eg GERD, gastric ulcer)
were not accounted; however they do not usually cause changes in BP until those resulting in significant
blood loss. Also the duration of PPI use before presentation was not known.
Conclusion: Oral PPI use on presentation seem to be associated with decreased Systolic and Diastolic
blood pressure among all chest pain patients presenting to emergency department.
Changing Internal Medicine Residency: Residents’ Perspective on an Alternative
4:1 Scheduling Approach.
First Author: Meghan A O'Halloran, MD Thea J Rogers, MPH; Frances M Weaver PhD
Purpose of Study:
Many have recognized the need to strengthen the residency ambulatory curriculum as outlined by the
2010 Associate Council for Graduate Medical Education regulations. Prior studies identified that
competing inpatient and outpatient responsibilities in a traditional resident schedule detract from
education. One solution is a unique recurring sequential 4:1 schedule. The schedule utilizes 4-week
inpatient rotations alternating with 1-week ambulatory rotations to optimize resident educational
experiences in each setting. Currently several residency programs use the 4:1 schedule but little is
known about residents’ perceptions on the impact of training.
Methods: An adapted 4:1 scheduling system was implemented to improve resident education. We
fielded a survey to evaluate residents’ perceptions concerning resident education, resident quality of
life, and patient care. Internal medicine categorical residents were surveyed 1 month before and 12
months after implementation of the new system. We analyzed differences between pre and postimplementation responses with Fisher Exact chi-square tests.
Results: The response rate was 98% both pre and post-implementation. Survey responses are reported
as proportions, where positive responses consist of ‘agree’ and ‘strongly agree’ responses. Residents’
positive perceptions improved post-implementation regarding key issues: internal medicine continuity
clinic maximizes ambulatory education (4% to 78%, p < 0.01); provides opportunity for good clinical
mentoring (30% to 78%, p < 0.01); provides good continuity of patient care (14% to 31%, p < 0.01);
provides confidence to safely practice outpatient medicine at the end of training (42% to 71%, p < 0.01);
and is an enjoyable and rewarding field of practice (36% to 63%, p < 0.02). Regarding inpatient care,
residents who agreed the continuity clinic schedule negatively affected inpatient educational
experiences decreased from 47% to 14% (p < 0.01), and that it negatively affected patient care
decreased from 68% to 2% (p < 0.01).
Conclusion: Categorical residents had a positive response to the adapted 4:1 schedule compared to the
traditional schedule. In both outpatient and inpatient settings, competing responsibilities decreased and
multiple aspects of resident education improved. The majority of improvements were noted in the
ambulatory setting. Further study should focus on a collaborative multi-institutional study of the impact
of the 4:1 schedule change in regard to resident, attending, and medical student perceptions.
Chapter Winning Abstract The Impact of Medication Reconciliation Initiative on
Hospital Readmissions.
Primary Author: Trinadha Pilla, MD, Co-Authors: Mehdi Shahidi, MD. Pisoh Watcoun-Nchinda, MD.
Kristina Dzara, PhD. Carrie Vogler, PharmD, BCPS Edgard Cumpa, MD.
Introduction: As the health care delivery system in the United States changes there is increase pressure
to control rising costs. Hospitals look into feasible options to counter these rising costs by having shorter
hospital stays with more focus on continuity of care. National readmission rates are about 21% and will
soon serve as a quality measure negatively impacting hospitals. Hospitals with “worse than expected”
30-day readmission rates would be penalized.
Non compliance and drug related problems including adverse drug events (ADEs) are important
preventable causes of hospital admissions. Previous studies estimated 12-17% of general medicine
patients experience ADEs after hospital discharge. 6-12% of these discharged patients with ADEs
resulted in ED visits. Of these ADEs 50% were preventable. This study was done to reduce hospital
readmission rates in our General internal medicine service (GIMS) by improving medication
reconciliation by pharmacists and residents by closely detecting and resolving medication discrepancies
and improve adherence by counseling patients prior to discharge.
Methods: The readmission rate for our GIMS from January 2011 to July 2011 was 19.02%. Analysis of
random 50 of these readmissions showed an average number of medications at the times of discharge
to be 9. Patients with more than 9 medications at the time of discharge were considered high risk and
were considered a potential target for medication reconciliation and counseling to prevent
Results: There were three teams A, B and C. Team C had a pharmacist and was the intervention group.
Pre intervention data from August 2011 to November 2011 showed readmission rates among the three
teams to be 21.9%, 28.9% and 17.3% respectively with a total average of 22.3%. In the post
interventions period a total of 47 patients were screened from December 2011 to March 2012. Prior to
discharge 50% of these high risk patients had medications related errors. 34% of these patients were
somewhat compliant and 8.5% were not compliant with their medications. The average medication
reconciliation at discharge took 13 minutes and 74.5% of these patients received counseling. The mean
number of time spent on counseling was 9.71 minutes. The study team did better overall on
readmissions (16.1% vs. 23.95% & 17.87%).The study team’s readmissions were slightly better than the
pre-intervention period (17.3% vs. 16.1; a 7% decrease). Overall, all the 3 teams did better than the preintervention readmission rates (22.3% vs. 19.3%; a 13.4% decrease).
Conclusions: Multiple factors do contribute to readmissions in hospitals. Identifying high risk patients
on admission and systematically eliminating medication related errors by utilizing a modified tool,
enhancing interdisciplinary approach for comprehensive medical reconciliation, counseling, incentives to
enhance compliance, overall increasing awareness at the time of discharge are important measures to
curb readmission rates.
Expedited Diagnosis Units : A paradigm shift in hospital practice?
Shashvat Sukhal, Shweta Gupta, Krishna Das
BACKGROUND Health reform and a focus on value-based care have caused hospitals to adopt
organizational changes to improve the efficiency of resource allocation. One example of this approach is
the use of observation units for conditions such as chest pain. Nations with
centralized health care systems have demonstrated the utility of specialized evaluation units, in the
outpatient setting, to expedite the diagnosis of conditions where inpatient observation is not necessary.
These units have access to specialized testing. This study was undertaken to evaluate the potential
impact of such an Expedited Diagnosis Unit (EDU) in avoiding hospital admissions.
METHODS Our hospital is a 464-bed teaching hospital in an urban setting. Patients admitted from the
emergency department (ED) to inpatient care in the first three months of 2012 were identified in our
electronic medical record system. Admitting diagnoses are assigned by the ED physician and the primary
team. Potential candidates for an EDU were defined as patients admitted for evaluation of a mass
lesion, anemia, minor GI-bleed, ascites or pleural effusion. Patients who had acute exacerbation of a
chronic condition, abnormal vital signs, or who required intensive care or admission following surgery
were excluded. Patients who met criteria for observation services were also excluded. The charts of
included patients were retrospectively reviewed for length of stay, procedures performed, inpatient
complications and final discharge diagnosis.
RESULTS A total of 4024 hospital admissions were screened of which 451 patients were potentially
eligible for the proposed EDU. Applying our inclusion and exclusion criteria, 139 were felt to be eligible
for an EDU and 312 were excluded. The admissions fell into four diagnostic categories: anemia (37%),
mass lesion/suspected malignancy (40%), uterine bleeding (9%), and miscellaneous conditions requiring
outpatient diagnostic workup (14%). Many of these patients had outpatient procedures scheduled and
the inpatient stay was primarily for coordination of care. If EDU had been implemented, it would have
avoided a total of 521 patient-days, with a saving of $1,302,500 for hospital bed cost alone (estimating
2500$ per day). This does not include savings on physician, nursing and ancillary services utilized.
CONCLUSIONS We have shown that a significant number of admissions to our hospital are for diagnostic
evaluations which can be safely and efficiently performed in an outpatient EDU. This potentially saves
thousands of dollars in inpatient care, much of which was primarily used for coordination of care. As the
proportion of admissions from the ED increases, and with an expected increase in the number of ED
visits related to health reform, alternatives to inpatient admission will become increasingly important.
Next steps would be to determine if these potential benefits could be realized in the actual
implementation of an EDU, which could be examined in a pilot project
Association of Body-Mass Index and Split Bowel Preparation Quality.
Khaled Abdeljawad, Nabil Fayad.
Purpose: Effective colonoscopy requires adequate colonic mucosa visualization, which itself depends on
bowel preparation (prep) quality. Recent studies suggest that obesity may be associated with
unsatisfactory prep quality. However, the prep type was not standardized and did not include split prep
regimens. In this study, we determine whether body-mass index (BMI) is an independent risk factor for
inadequate prep in patients who receive a split prep regimen, and determine a cutoff BMI for patients
who may require more intensive prep.
Methods: This retrospective study was conducted at the Roudebush VA Medical Center in Indianapolis,
Indiana. Patients who underwent elective outpatient colonoscopy between 1/1/2009 and 12/31/2009
were eligible. Exclusion criteria were emergent procedures, individuals with BMI < 18.5, prior colon
resection, incomplete colonoscopy for reasons other than inadequate prep, and repeat colonoscopy
within the study period. All patients received a polyethylene glycol-based split bowel prep. Patient data
collected included demographic and physical variables, comorbidity as measured by the Charlson score
and count, and medications. Colonoscopy data collected included indication, prep quality, and findings.
Prep quality was categorized as adequate (excellent or good on the Aronchick scale) or inadequate (fair,
poor or unsatisfactory). Multivariable logistic regression analysis was performed to determine factors
independently associated with inadequate prep.
Results: 484 patients were included in this interim analysis. Mean age was 60.2 ± 10.9 years; 93.3% were
male; 84.9% were Caucasians. The mean Charlson score was 1.4 ± 1.6. 82 patients had a normal BMI
(16.9%); 173 were overweight (35.7%) and 229 were obese (47.3%). The prep quality was excellent in 4
patients, good in 249, fair in 171, poor in 53 and unsatisfactory in 7. Overall, 253 patients (52.3%) had an
adequate prep and 231 (47.7%) had an inadequate prep. The two groups were comparable for age,
gender, race, and Charlson score. Patients with inadequate prep had a mean BMI that was higher (31.2 ±
6.2 vs. 30.0 ± 5.7, p=0.0189), had a higher Charlson comorbidity count (1.3 ± 1.4 vs. 1.1 ± 1.2, p=0.0193)
and were more likely to be on anticonvulsant therapy (7.4% vs. 3.2%, p=0.0372). Multivariate analysis
showed that higher BMI was an independent risk factor for inadequate prep quality, after adjusting for
the Charlson comorbidity count and use of anticonvulsants. BMI > 28 was predictive of inadequate prep
(OR 2.01; CI 1.37-2.95; p=0.0003).
Conclusion: BMI is an independent predictor of inadequate colonoscopy prep quality among patients
using split bowel preps. A BMI > 28 kg/m2 is associated with inadequate prep quality. Ongoing analysis
on a larger sample size will further refine BMI cutoffs and generate a risk score to help select patients
who may require more intensive prep.
The Effect of establishing evidence based guidelines for COPD
Luis O. Nunez MD Vru Patel MD Stephen Knaus MD. Department of Medicine, St Vincent Hospital,
Indianapolis Indiana
Introduction: Chronic obstructive pulmonary disease (COPD) is a treatable disease. Most complications
are characterized by airflow limitation that is irreversible and progressive. The majority of cases are
attributable to tobacco smoke but up to 20% of patients are non-smokers. COPD is a leading cause of
morbidity and mortality worldwide with tremendous social and economic burden. It is estimated that
$18 billion in direct and $14 billion dollars in indirect cost are spent in the US alone. Our goal was to
review the management of COPD patients in the Primary Care Clinic (PCC), specifically comparing
outcomes in patients treated in a clinic dedicated to the care of patients with COPD with patients cared
for in the residency clinic at large. Patients in the COPD clinic receive care directed at their disease state
with education and spirometry from a respiratory therapist and an internal medicine resident paying
close attention to meeting GOLD (Global Initiative for Obstructive Lung Disease) criteria.
Methods: All patients with a diagnosis of COPD seen at the PCC were used in our QI project. Our primary
goal was to show that compliance with treatment recommendations based on GOLD criteria can
decrease COPD-related hospital admissions, slow disease progression, increase smoking cessation, and
improve quality of life.
Results: Objective data collected included FEV1%, pulse oximetry, smoking cessation, and incidence of
COPD-related hospital admissions. Exclusion criteria included severe COPD, home oxygen, chronic
steroids for any medical condition, non-compliance with medication use, direct care of pulmonologist,
no follow up pulmonary function testing (PFT) at least 9 months after baseline PFT. Only 12 patients out
of the total of 250 met criteria: six patients from the PCC clinic and 6 from the COPD clinic. Six out of 6
patients in the COPD clinic met GOLD- based treatment compliance but only 2 out 6 in the PCC. COPD
clinic patients did not have COPD-related hospital admissions vs. 1 out 6 in the PCC group. Finally,
smoking cessation in the COPD clinic was 100% cessation vs. only 66% cessation in the PCC group.
Conclusion: Patients treated in a clinic dedicated to care of COPD had better compliance with GOLD
treatment recommendations than patients treated in our general residency clinic. Smoking cessation
was improved and hospitalizations for COPD were fewer in the COPD clinic group. The small number of
patients limits firm conclusions, but early data suggest improved outcomes in a residency clinic with a
clinic dedicated to care of COPD.
Intrapulmonary Shunt Is A Potentially Unrecognized Cause Of Ischemic Stroke And
Transient Ischemic Attack
First Author: Nirmanmoh Bhatia, MD Second Author: Mohannad Y Abushora, MD Third Author: Ziad
Alnabki, MD Fourth Author: Marcus F Stoddard, MD
Introduction: Ischemic stroke is a major cause of mortality and disability. Transient ischemic attack (TIA)
is a harbinger of stroke. After an extensive evaluation, the etiology of stroke in as many as 40 percent of
patients remains undetermined. It was hypothesized that intrapulmonary shunt is a potential
independent facilitator of cerebrovascular accident (CVA) or TIA.
Methods: Patients scheduled for transesophageal echocardiography (TEE) which met inclusion and no
exclusion criteria were prospectively enrolled. Inclusion criteria were age = 18 years, sinus rhythm and
clinically indicated TEE. Exclusion criteria included hemorrhagic CVA, non-embolic neurologic event,
septal defect, oxygen saturation = 90% and atrial fibrillation. Comprehensive multiplane TEE using
second harmonic frequency imaging was performed and saline contrast done to assess for
intrapulmonary shunt and patent foramen ovale.
Results: Five hundred twenty-three subjects with either non-hemorrhagic CVA (n= 424) or TIA (n=99)
made up the "Stroke" group. Three hundred fifty-one patients without prior CVA or TIA had TEE for
other indications and made up the "Control" group. The Stroke group was older than the Control group
(61 ± 15 vs. 54 ± 15 yrs, P < 0.0001). Intrapulmonary shunt occurred more frequently in the Stroke
(85/523) as compared to the Control (34/351) group (16% vs. 9.7%, P < 0.01). Among clinical and
echocardiographic variables, advancing age, decreasing ejection fraction, hypertension, hyperlipidemia,
poor right ventricular function and presence of intrapulmonary shunt were the independent
multivariate predictors of CVA and/or TIA (P < 0.0001). In subjects with intrapulmonary shunt, the shunt
severity and number of pulmonic veins involved did not differ among the Stroke and Control groups.
Conclusions: These results suggest that intrapulmonary shunt is a potentially unrecognized facilitator of
CVA and TIA. Future studies assessing the prognostic significance of intrapulmonary shunt on cerebral
vascular event recurrence rate in patients after initial CVA or TIA would be of great interest.
The hyperuricemia causing Q141K mutation of ABCG2 uric acid transporter leads
to improper protein folding and ER associated protein degradation that can be
rescued by the small molecule corrector VRT--325
Deepali.N.Tukaye, William.B.Guggino and Owen.M.Woodward
Introduction: Heart failure (HF) accounts for substantial morbidity and mortality in the world. In the US,
each year approximately 5 million suffer from HF and 400,000 are newly diagnosed. With increase in the
population over 65yrs, these numbers are expected to increase further. The estimated cost of HF in US
ranges from $25-50 million. Multiple studies indicate that hyperuricemia and oxidative stress contribute
causally to HF. ABCG2 knock-out has been shown to cause oxidative stress in tissues. ABCG2 is also
avidly expressed in the cardiac stem cells that can be isolated for stem cell therapy in HF. Recent
genome wide association studies have identified a single nucleotide polymorphism (Q141K) of ABCG2
gene, that strongly correlates with increased serum urate levels. ABCG2-Q141K has a high population
frequency of (10% whites of European decent; 30% Asians), and the reduced transport efficiency and
expression may contribute significantly to overall occurrence of hyperuricemia. Understanding the
cellular processing of ABCG2 may provide insights into pathophysiology and management of
hyperuricemia and oxidative stress. Here, we investigate the molecular pathophysiology of ABCG2Q141K.
Methods and Results: Studies were done in LLPCK1, HEK293 and oocytes. In mammalian cells, the
Q141K mutation resulted in reduced ABCG2 protein expression and C14-Urate efflux at 37°C when
compared to wild type (WT). An alignment of ABCG2 with ABCC7 (CFTR) reveals that the Q141K
mutation is adjacent to F142, homologous to F508 of CFTR. The Cystic Fibrosis causing ?F508 is a misfolding defect that increases protein degradation. We hypothesized that Q141K corrupts proper ABCG2
folding thereby increasing its degradation. Incubating HEK-293 cells expressing ABCG2-Q141K at 27°C
increased the total and surface amounts of the protein compared to incubation at 37°C. Further,
deleting ABCG2-?F142 resulted in significant reduction in total protein expression. Also, ABCG2-Q141K
demonstrated an increased sensitivity to ENDO-H deglycosylation compared to WT, suggesting a
variation in the complex glycosylation pattern consistent with differences in protein folding. In addition,
ABCG2-Q141K degradation is rescued by the suppressor mutation G188E, homologous to the suppressor
mutation in CFTR-?F508. Finally, the chemical chaperon, 4-phenyl-butyric-acid, rescued ABCG2-Q141K
from degradation at 37°C. These results provide strong evidence towards ABCG2-Q141K being an
improperly folded variant targeted to the proteasome for rapid degradation. Based on this evidence,
screening small molecule correctors that target protein trafficking pathways showed that VRT-325
significantly increased the total and surface levels of ABCG2-Q141K and WT ABCG2 at 37°C. In addition,
sequence analysis of ABCG2-Q141K vs. WT reveals changes in the sites for restriction enzymes that can
be exploited to test the presence of the variant gene in individuals in a cost effective manner.
Conclusion: ABCG2 is an important player in urate handling and the high prevalence of ABCG2-Q141K
mutation necessitates a greater understanding of its defects and implications in hyperuricemia,
oxidative stress and possibly heart failure. In this study, we have shown for the first time that the
ABCG2-Q141K mutation results in protein mis-folding with rapid ER associated degradation and
decreased rate of uric acid efflux. We also show that small molecule correctors targeting ERAD can
rescue the trafficking defect of ABCG2-Q141K unveiling strategies for developing newer treatments for
hyperuricemia and oxidative stress.We have also developed a cost effective genetic test for
identification of the variant gene in the population.
Implementation of a protocol for ABG use increases the diagnostic yield while
reducing unnecessary tests
First Author: Jeffrey DellaVolpe, MD
This study examined indications for arterial blood gas (ABG) use hypothesizing that implementation of a
protocol of evidence based indications for ordering ABGs would result in a reduction of the total number
of ABGs, ABGs “not indicated” according to the protocol, and routinely ordered ABGs without a specific
clinical indication.
Methods: We developed a protocol for ABG indications based on previously published guidelines and
the needs of our institution. Exclusion criteria included age < 18, stroke patients, and venous blood
gases. Indications were recorded for 6 weeks by respiratory therapists prior to implementation. All staff
and residents were then trained on the protocol and indications were recorded for 6 additional weeks.
Results: After implementation of the protocol, there were significant reductions in total ABGs (p<0.001)
and “not indicated” ABGs (p<0.012). The average ABG/patient/day decreased 24.8% from 0.353
ABGs/patient/day to 0.265 ABGs/patient/day (p<0.0003), with no change in mortality between the
study groups.
Amongst non-ventilated patients, there was a significant reduction (p<0.001) in ABGs ordered for
“difficulty oxygenating.” In ventilated patients, there was a significant reduction in ABGs ordered for
changes in PEEP (p<0.03), daily blood gases (p<0.001), and weaning trial ABGs (p<0.004) after
implementation. ABGs ordered for change in minute ventilation increased by 15.6% (p<0.004), while
daily ABGs decreased by 14.4% (p<0.001) and weaning trial ABGs decreased by 15.4% (p<0.004). The
number of abnormal ABGs increased 16% when ordered for a change in minute ventilation (p<0.006)
and decreased 13.5% when ordered as a daily ABGs (p<0.001). There was no change in the number of
normal ABGs.
Developing a clinical rationale for ordering ABGs is a shortcoming in the training of many clinicians. This
project offers one approach, as well as empiric data on its effectiveness. Using this protocol, clinicians
ordered fewer tests overall and ordered a higher proportion of ABGs based on changes in clinical status.
Moreover, those ordered for changes in clinical status were more likely to be abnormal.
In addition to facilitating more targeted and appropriate use of ABGs, this approach also reduced ABGs
use 24.8%. Cost minimization analysis estimated national cost savings to be $128 million annually for
this intervention. For a test as prevalent, invasive, and expensive as the ABG this study represents an
important step towards judicious and meaningful use of medical resources.
Trends in Cancer Survivorship Care- Lessons from a large Institution based Cancer
First Author: Rutika J Mehta, MBBS Second Author: Rohit K Jain, MBBS Third Author: Lori Hrodes Fourth
Author: Kenneth Miller, MD
The number of cancer survivors in the United States has shown a dramatic increase from 3 million in
1971 to 11.7 million in 2007. Almost 50% of more than 10 million survivors in 2007 were diagnosed 10
or more years ago. In light of these paradigm shifts, policy makers and survivorship advocates are
making strides towards improving the quality of care provided to cancer survivors in each of the
"seasons of survivorship” including acute, transitional, extended, and permanent. The purpose of this
study was to characterize the health problems and care of cancer survivors at a major NCI Designated
cancer center in 1-5, 6-10, and >10 years post-treatment.
Data was collected in three phases. 1) Characteristics of a group of 19,000 individual cancer survivors
seen at a major cancer center in 2010, 2) Collecting clinical data on patients seen during a randomly
selected week in 2010, 3) Characterizing the care provided for groups of 100 survivors at 1-5, 6-10, and
>10 years post-treatment.
In almost 19,000 individual cancer survivors the percentage at <1, 1-5, 6-10, and >10 years postdiagnosis were 19%, 50%, 19%, and 14% respectfully. Females comprised significant proportion of
survivor population with mean ratio of 1.9(p<0.001). Breast cancer survivors comprised 38% of the
survivor population followed by hematologic malignancies (21%). During one randomly selected week
the visit percentages were 71, 25, 3, and 1% post-diagnosis indicating that the majority of providers'
time was spent with patients actively receiving treatment who have multiple visits each year. Second or
secondary malignancy was noted in 8% of the patients, 18% of which were acute survivors undergoing
treatment. Sixty two percent patients received only surveillance care during the visit. Only 3% patients
received an entire array of survivorship care that included surveillance, intervention, co-ordination and
prevention. Only 76 patients were observed to have late effects due to cancer treatment, most common
being neurological (28%) and constitutional (22%) complications some of which included chronic pain,
depression, peripheral neuropathy, fatigue etc. The association of developing late effects from
treatment with the complexity of care received during oncologic visit was statistically significant (p
Our conclusion is that Oncologists spend the majority of time providing care for acute survivor visits and
fewer visits are with long term survivors .There is little focus on prevention and intervention for cancer
survivors. In short, there is increasing concern that cancer survivorship is low on the radar screen of
cancer care providers and more attention is required.
Chapter Winning Abstract -- Outcomes of Inpatient-To-Outpatient Suboxone
Therapy for Heroin Addiction
First Author: Charmian D Sittambalam, MD; Secondary Author: Robert Ferguson, MD
Introduction: Opioid dependence treatment traditionally involves methadone clinics, for which
dispensing schedules can be cumbersome. Buprenorphine, a partial agonist of the mu receptor and
antagonist of the kappa receptor, is a potential outpatient alternative to methadone. Funded by a grant
from the State of Maryland’s Community Health Resources Commission (CHRC), the Buprenorphine
Outpatient Outcomes Project (BOOP) evaluates the outcome of Suboxone treatment on abstinence from
heroin use, rates of emergency room visits and hospitalizations, legal issues, and quality of life.
Methods: IRB approval to commence the BOOP study was sought and successfully obtained. Active
heroin users were recruited between June 2007 and June 2010 and identified as candidates through
clinical history, urine toxicology results, and pharmacy orders. Informed consent was obtained and
induction therapy with Suboxone was instituted during hospitalization. Once discharged, patients were
followed as outpatients for maintenance treatment and counseling. Data was collected from electronic
medical records, Maryland state legal records, and SF-36® Health Surveys regarding demographics,
epidemiological and clinical parameters, criminal charges, and quality of life measures. Patients were
categorized according to duration of treatment with Suboxone into one of three groups: < 1 month, 1-3
months, and > 3 months. Follow-up of the patient cohort will continue until June 2011.
Results: 220 participants were included in the study. The age range of participants was 18-67 years old
with 85% (n=186) being African American and 63% (n=138) being male. 137 (62%) remained in the
study for < 1 month. 83 (38%) remained in the study for at least 1 month, with 37 of the 83 (45%)
remaining in treatment for > 3 months. Nine of the 37 (24%) never relapsed after their longest period
of abstinence from heroin. During the first year after initiating treatment with Suboxone, hospitalization
and emergency room visit rates for all 220 participants decreased by 47% and 27%, respectively, as
compared to the year prior to starting treatment. While the total number of criminal charges increased
in the year after starting treatment (221 charges prior to treatment versus 237 charges after starting
treatment), the number of charges for drug possession decreased from 70 to 62. Anecdotally, the
quality of life seemed to improve in those who were treated with Suboxone for longer periods of time
and received regular counseling.
Conclusion: Overall, Suboxone is an effective treatment method for heroin addiction and is a viable
outpatient therapy option. Individualized treatment plans and counseling must be implemented for
maximum benefits to be seen. Retention of patients for a long duration of therapy was difficult, but for
those who did remain, benefits were seen in overall health, abstinence from heroin use, cognition, and
quality of life.
Predicting Readmission within 30 days of Discharge after CHF and Pneumonia: A
Community Hospital Experience
Sandeep Somalaraju, MD, Jessica Lynch, MD, Dhaval Shah, MD, Dahlia Banerji, MD, Susan George, MD,
FACC, George Abraham, MD, MPH, FACC
Introduction: Congestive heart failure (CHF) is the leading cause of hospitalization among Medicare
beneficiaries and accounts for more healthcare costs than any other diagnosis. Pneumonia (PNA) is the
second leading cause among this cohort. Despite ongoing research, consistent and reliable predictors of
readmission for both these conditions remain elusive. The national average of 30-day readmission after
CHF and PNA is 26.8% and 18.7% respectively, while the rates at our hospital are 24.7% and 18.5%
respectively. We sought to compare our hospital’s current case management (CM) readmission risk
prediction tool with the standard Yale model and aimed to develop a better predictor tool for both
these conditions.
Methods: A 6-month retrospective chart review was performed of all patients admitted between May
2011-October 2011 with CHF and PNA. Patients with even numbered medical record numbers were
included. Each patient’s data was entered in the online Yale calculator and a risk score was calculated.
The Yale score was based on objective data of demographics, symptoms on initial presentation, history,
physical exam and diagnostics. Corresponding data was compared with the existing CM tool, which was
based on a combination of criteria spanning broad groups of medical complexity, functional/cognitive
status and social factors. Statistical analysis was performed using SAS and SPSS.
Results: Of a total of 85 patients in the CHF cohort, 39 (45.9%) were readmitted for all-cause (mean age
80 years, 51.8% male). Using multivariate analysis on both tools again here, independent predictors of
readmission were identified. These included living alone, history of COPD, aortic stenosis, diabetes
mellitus, myocardial ischemia, dependence for ADL’s, transferring, care plan, hypotension on admission
and renal failure.
In comparison of the 55 patients with PNA, 20 (36.3%) were readmitted for all-cause (mean age 78
years, 49% male). Multivariate regression analysis with both the CM and Yale tools combined identified
independent predictors of readmission: presence of CHF, BUN < 30, serum Na < 130, history of frequent
falls and unresolved dyspnea on discharge, with a sensitivity of 75% and a specificity of 74.3%, p<0.05.
Conclusion: Independent predictors of 30-day readmission in our patient cohort have been identified
although some are modifiable and some are not. Using early intervention of modifiable risk factors
preventable readmissions may diminish. The results of our study thus far have been relayed to the
Quality Improvement team and initial interventions have shown promising results. A prospective study
is required to validate our modified tool.
Circulating microRNAs are associated with Paroxysmal or Persistent Atrial
Amir Y Shaikh, MD; David D. McManus, MD; Jeanine A. Ward, MD PhD; Victor Ambros, PhD; Jane E.
Freedman, MD; John F Keaney Jr., MD ^ From the Department of Internal Medicine, University of
Massachusetts Medical School; * From the Division of Cardiovascul
Introduction: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, but
little is known about the gene regulatory mechanisms underlying this arrhythmia and novel methods of
identifying individuals at risk for this arrhythmia are needed. MicroRNAs (MiRNAs) regulate gene
expression in a number of cardiovascular diseases, including AF. It is unknown, however, if key
circulating, cardiac-specific miRNAs differ between individuals with paroxysmal or persistent atrial
fibrillation (AF) and those in sinus rhythm. We tested the hypothesis that cardiac-specific miRNAs are
associated with paroxysmal or persistent AF.
17 individuals with a history of paroxysmal or persistent AF (cases) were recruited prior to catheter
ablation. Twenty-four hospitalized patients in normal sinus rhythm and no history of AF comprised the
control group. Plasma was isolated from K2EDTA venous blood samples using standard techniques. 94
plasma miRNAs were selected based on a priori associations with processes implicated in AF for
evaluation using the TaqMan miRNA expression profiling system.
We found that miRNA expression differed by at least 2-fold for 14 miRNAs, including several previously
implicated in cardiovascular remodeling and disease. Levels of miR-7, miR-208, and miR-302b were
statistically significantly up- or down-regulated in AF patients relative to controls (p<0.05) and levels of
miR-218 differed by greater than 20-fold (p=0.095).
Although power was limited by the modest sample size, these data support the rationale for using
circulating miRNA as AF biomarkers. Moreover, since miRNA can modulate disease pathways, miRNAbased therapeutics would theoretically enable targeting of novel gene regulatory pathways implicated in
AF in a unique and powerful manner.
Next Steps/ Future:
Further investigations involving well-characterized, large samples from longitudinal studies with
standardized miRNA assessment and evaluation for AF are required to validate the observed
Predictors of Relapse in Clostridium difficile Associated Diarrhea (CDAD)
Jagriti Upadhyay, MD Alwyn Rapose, MD
Predictors of Relapse in Clostridium difficile Associated Diarrhea (CDAD)
Jagriti Upadhyay, MD (Associate) and Alwyn Rapose, MD,
Department of Medicine, Saint Vincent Hospital, Worcester, MA
Background: CDAD continues to manifest with increasing incidence and severity. High rates of
recurrence have lead to increased hospital readmissions, morbidity and mortality related to Clostridium
difficile infection (CDI). The search for a “cure” has resulted in development of newer therapies like fecal
transplant, monoclonal antibodies, vaccines, and fidaxomicin. A study to investigate the risk factors of
relapse in CDAD would potentially help in targeted use of advanced therapies which decrease
recurrence of CDI.
Our study aimed to determine the clinical variables that may predict CDAD relapse. We also revisited the
role of fecal leukocytes in prediction of relapse.
Methods: Retrospective chart analysis of the patients hospitalized with diagnosis CDAD over one year
period was performed. Only first episodes of CDAD with a 6-month follow-up were studied. Abstracted
data included standard demographics, prior antibiotic and proton pump inhibitor (PPI) use, laboratory
data and fecal WBC at admission. Relapses of CDAD were recorded by review of electronic medical
Results: Charts of 104 patients were reviewed; 20 patients were admitted for a relapse and hence
excluded, 23 patients expired, and 1 was lost to follow-up. Of the 60 remaining patients, 14 (23%) had a
relapse in the 3 months following discharge; 10 of 30 (33%) > 80 years of age relapsed, in contrast to 4
out of 30 (13%) of those < 80; 10 of 25 (40%) with positive fecal leukocytes relapsed, while only 3 of 23
(13%) with negative fecal leukocytes relapsed (p=0.02); 20% of the patients with exposure to a single
antibiotic course in the previous 6 months relapsed, while 33% relapsed who received two and more
courses of antibiotics over the previous 6 months. The well known predictors of mortality associated
with CDAD including peripheral WBC >15,000, community versus facility acquired CDAD, glycemic
control and duration of hospital stay, however did not show any relationship to the relapse rate in our
current study. Interestingly, use of PPIs was associated with decreased risk of recurrence (OR 0.18,
p=0.06). A combination of age > 60 years and positive fecal WBC was associated with a relapse rate of
42% (8 out of 19) as compared to no relapses in patients with a combination of age < 60 years and
negative fecal WBC.
Conclusion: Our data suggests that age > 60 years; fecal leukocyte positivity and exposure to multiple
antibiotic courses prior to initial CDI predisposes patients to relapse. These simple predictors may help
physicians to dispense newer, advanced treatment to patients at risk. Larger prospective studies are
warranted to confirm the findings of our analysis.
Psychological Stress Management with Increased Physical Activity: A Study in
Internal Medicine Resident Physicians in Training
First Author: Ridhwi Mukerji, MD Vanessa Pauig, MD Kalyan Uppaluri, MD Shagufta Ali, MD, FACP
Introduction: The Accreditation Council for Graduate Medical Education (ACGME) recognizes that
patient safety and resident well-being are tied together. There is substantial data in other professional
groups regarding the role of physical activity to decrease depersonalization and emotional exhaustion
and increase the sense of personal accomplishment. And, in residents decreasing stress has been shown
to improve patient care. The aim of our quality improvement (QI) project was to increase baseline
physical activity by 50% in internal medicine residents at our institution assuming a corresponding 20%
improvement in their stress and burn-out levels based upon other studies.
Methods: Following Institutional Review Board approval and informed consents, we collected baseline
data on stress and burn-out levels using the Maslach Burnout Inventory-Human Services Survey (MBIHSS), on well-being using the WHO Well-being Index and on physical activity using pedometer readings
(all validated instruments). Interventions included presentations to the residents about our QI project,
distribution of pedometers and publication of a cash prize for the resident achieving the greatest
increase in pedometer reading from baseline. Post-intervention scores on the survey instruments and
cumulative readings on pedometers for individual participants were calculated and analyzed for
Results: Final analysis was based on 41.7% of our study population, the data being incomplete in the
remaining. It showed that 53.3% of the studied participants had more than a 50% increase from their
baseline physical activity whereas 13% of the participants had no change. Among the group with more
than a 50% increase in physical activity, the Maslach Burnout Inventory subscale analysis showed 73.3%
of the participants had a decrease in emotional exhaustion and depersonalization with more than 20%
improvement in their scores across the board, meeting our QI goal. Also 73.3% showed improvement in
personal accomplishment out of which 46.7 % showed improvement greater than 20%. In addition
86.7% of that group showed improvement in their WHO Well-being Index scores.
Conclusion: In conclusion, we demonstrated that burnout levels had a negative correlation with physical
activity in our internal medicine resident population, whereas well-being was positively correlated, a
result similar to that found in published studies on other populations. Hence, residents should be
encouraged to increase their physical activity. Our QI project’s success was limited by non-compliance
of pedometer usage and inconsistent submission of data.
First Door-to-Balloon Time (1stD2B): Improving Door-to-Balloon Time in Patients
Transferred for Primary Percutaneous Intervention.
First Author: Yousif T Ismail, MBCHB ,Sachin Kumar Amruthlal Jain MD, Patrick Alexander MD, Michael
Shaw PhD and Shukri David MD
We identify the delay in the first door-to-balloon time (1stD2B) in patients with acute STEMI requiring
transfer to a PCI capable hospital with post hoc implementation of novel initiative “Register and Roll” to
improve D2B
National guidelines established by the ACC/AHA call for D2Bb of = 90 minutes for patients presenting
with STEMI undergoing PCI. In patients presenting to non-PCI capable hospitals the D2B = 90 min is met
in only 8.6% of patients
A retrospective analysis was performed from April 2006 to May 2009 in STEMI patients transferred to
Providence Hospital from non-PCI capable hospitals. Patient’s charts were reviewed. Patients under 18
years of age were excluded. The” Register and Roll Initiative” designed to facilitate transfer to PCI center
was implemented in patients starting in June 2009 to December 2010
148 patients were transferred with 47 patients included post “Register and Roll”. Three local hospitals
were involved with an averaging a distance of 16.4 miles. Time to ECG,to EMS activation,door-in-doorout, EMS transport time. D2B time was compared pre and post implementation. The door in-door out
time played a major role in prolonging the time to reperfusion and after implantation.Patients were
transferred sooner for PCI resulting in improved 1stD2B. (140 vs. 100 min)
Our novel initiative, “Register and Roll” involves simple guideline, a CATH KIT and EMS notification,
which improved delays in timely request for EMS and thereby door-in-door-out time. This initiative is
simple to follow in a community hospital setting, where resources are limited
Patient Centered Medical Home (PCMH) in Residency Programs
First Author: Shafik Boyaji, MD
Patient Centered Medical Home in Residency Programs
Shafik Boyaji, Amanda Gittus, Mark Schauer, Susan Bannon, Imad Bagh, Lorenzo Zaffiri.
The Patient Centered Medical Home (PCMH) care model has evolved as an approach to provide
comprehensive and high quality patient care. The PCMH care model includes ongoing management of
all of the patients’ needs, including compliance with preventive screenings, enhanced access for acute
illness, evidence-based management of chronic diseases, care coordination and integration of
behavioral health need.
The PCMH has six standards that align with the core components of primary care:
Enhance Access and continuity
Identify and manage patient population
Plan and manage care
Provide self-care and community resources
Track and coordinate care
Measure and improve performance
The Patient-Centered Primary Care Collaborative (PCPCC) has published a review of 46 medical home
initiatives throughout the United States in 2012. This demonstrated an improvement in quality and
outcomes and a reduction in costs (the “Triple Aim”).
There were some speculations that residency programs will not be able to adapt the PCMH care module
because of the multiple requirements and standards and the amount of work, efforts, organization and
commitment that would be necessary from the programs. We at Western Michigan University/School of
Medicine (WMU/SOM) residency program are proud to announce that we were the first residency
program to be approved as a PCMH by the Joint Commission and the National Committee of Quality
Assurance (NCQA). It was the result of hard teamwork between the residents, faculty, nursing and
administrative staff, and we are happy to share our experience with others.
Through the use of our Electronic Medical Records (EMR) we were able to apply clinical practice
guidelines to certain medical conditions including Diabetes, Hypertension and Pain Management.
Preliminary data show that since implementing a consistent and patient centered approach to diabetes
and hypertension care in January 2012, we have already seen an increase in the numbers of patients
who are meeting all ADA (American Diabetic Association) and AHA (American Heart Association)
standards of care, including appropriate follow-up, screening (eye exams and proteinuria),
immunizations, and intervals for lab testing (LDL and hemoglobin A1C). Compliance with these
measures has increased across the board in our primary care clinics as we have placed greater emphasis
on education and consistently following nationally recognized standards.
In January of 2013 (1 year after implementing our improvements in the standardization of care) we will
evaluate the level of control of our patients in the Internal Medicine Clinic by looking at Hemoglobin
A1C, LDL levels, and consistency of starting an ACE-Inhibitor in patients with proteinuria in our diabetic
patients, and looking at level of blood pressure control and LDL levels in our hypertensive patients.
Vamcomycin MIC as a Predictor of Infective Endocarditis in Patients with MRSA
First Author: Pablo Buitron De La Vega, MD Waqas Qureshi, MD Parul Tandon, OMS Youssef Nasr, MD
Samia Arshad, MPH Daniela Moreno, MPH Gordon Jacobsen, MS Syed Hassan, MD Chetan Mittal, MD
Rachna Jayaprakash, MD Mayur Ramesh, MD Marcus Zervos, MD
Background: High vancomycin minimum inhibitory concentration (MIC) has been shown to be a
predictor of mortality in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Our purpose
was to study the relationship of high vancomycin MIC as an independent predictor of infective
endocarditis (IE) in patients with MRSA bacteremia.
Methods: All patients with MRSA bacteremia from 2005 to 2009 at our institution were retrospectively
evaluated for MIC by Etest. Infective endocarditis was established using modified Duke's criteria. A
detailed review of charts and social security index was carried out. Various predictors of MIC = 2 were
studied and survival analysis was studied by Kaplan Meier's method.
Results: Overall 398 patients (mean age 58.6±17.1 years, women 40.2%), with MRSA bacteremia were
included. Definite IE was diagnosed in 44 (11%), 119 (29.9%) had possible IE and 235 (59%) were
negative for IE. MIC = 2 was associated with mortality (HR 4.2; 95% CI 2.6 - 6.7, p <0.0001). Patients with
vancomycin MIC = 2 did not show statistically significant association with diagnosis of IE (p = 0.301),
hemodialysis, AICD infection, cardiac structural or valvular abnormality, treatment with vancomycin in
30 days, prosthetic heart valve, new onset heart failure, implantable intravenous catheter.
Conclusion: MIC level =2 is not a good predictor of IE however, it should be taken into consideration as
it represents a strong predictor of mortality in patients with MRSA bacteremia and may impact decisions
regarding their treatment.
Purpose: To determine the disease-free survival and post treatment toxicity following salvage
permanent prostate brachytherapy (sPPB) as a second curative treatment in patients with biopsy proven
local recurrence after initial external beam radiation treatment (EBRT) for prostate cancer.
Materials and Methods: Between June, 1996, and December 2007, 23 patients were treated with sPPB
for histologically confirmed locally recurrent adenocarcinoma of the prostate. Prior to the initial EBRT,
all patients had Stage T1 or T2 disease. Fifty percent (12) had a Gleason score < 6, eight had a Gleason
score 7, and 3 had a Gleason score of 8. The median pre-EBRT PSA level was 8.02 ng/ml (range 5 to 16.4
ng/ml). All patients had histologic confirmation of residual cancer within the prostate by transrectalultrasound guided biopsy. The median pre-implant PSA level was 5.0 ng/ml. After a staging evaluation
documenting no metastatic disease, all patients received permanent implantation of iodine-125 (21 pts,
median dose 145 Gy) or palladium-103 (2 pts, median dose 100 Gy) using a transperineal ultrasoundguided technique. Biochemical failure after brachytherapy was defined according to the ASTRO
Consensus Conference definition. Gastrointestinal (GI) and genitourinary (GU) toxicity were defined
according to the RTOG/EORTC scoring system.
Results: The mean follow-up after salvage brachytherapy was 4.4 years (range 1 to 12 years). At the
time of last follow-up 16 of 23 (69.5%) patients had no evidence of disease. One of these patients
remains on adjuvant hormonal therapy. Pre-EBRT Gleason Score (p = 0.092) and pre-EBRT PSA level (p =
0.093) were associated with outcome after salvage brachytherapy. In evaluating the characteristics of
patients at the time of their salvage implant, only the pre-implant PSA level was a statistically significant
predicator of outcome (p = 0.05).
Five patients had Grade 1-2 GI and/or GU toxicity following sPPB. Two patients had a Grade 3
complication; hemorrhagic cystitis and incontinence in one patient, and a urethral stricture requiring
internal urethrotomy in another. One patient had a grade 4 complication, necrosis of the anterior pubic
symphysis requiring urinary diversion.
Additional follow up data has been obtained at the time of submission and will be included in final
presentation. This extends mean follow up to 8.2 years.
Conclusion: These results suggest that ultrasound-guided transperineal prostate brachytherapy in
selected patients with locally recurrent prostate cancer after EBRT may be an effective second curative
treatment. Serum PSA level at the time of salvage implant was the best predictor of treatment success.
sPPB should be considered an option in these patients as the toxicity profile appears favorable
compared to salvage prostatectomy and cryotherapy. Further study is needed to determine factors for
identifying patients that have the best chance for a favorable outcome.
Procalcitonin as a valuable marker to detect bacterial infection in ESRD patients
First Author: Amy H Attaway, MD Second Authors: Rasha Abdulmassih, MD Thomas Flynn, MD Anita
Charochak, DO Matthew Zaccheo, DO
Introduction: Procalcitonin (PCT) is a peptide normally produced by C cells of the thyroid gland. During
a bacterial infection, LPS and various cytokines (IL6, TNFa, IL2) stimulate the expression of PCT mRNA
leading to its increased excretion by cells of the immune system. To date, PCT has emerged as a valuable
aid in diagnosing bacterial sepsis, and has helped decrease antibiotic use in the critically ill without
increasing mortality.
Early detection of bacterial infection and sepsis has been a challenge for end stage renal disease (ESRD)
patients given the decreased accuracy of other inflammatory markers like WBC, ESR, and CRP.
Methods: From January to September 2012, 33 ESRD patients (on hemo or peritoneal dialysis)
presented to Bronson or Borgess hospital in Kalamazoo, Michigan. They were included if they met
criteria for sepsis, severe sepsis, or septic shock, and had a clear infectious source. Their values were
compared to a control group of 63 patients without underlying immunodeficiency who met the same
criteria and had positive blood cultures. PCT was measured upon admission. APACHE II scores were
calculated to help control for severity of disease between groups.
Results: The average PCT for the ESRD group was found to be 17.1 (average APACHE II of 17.4)
compared to 42.2 in the control (APACHE II of 15.9). APACHE II scores were found to correlate
significantly with the degree of elevation of PCT in both groups (ESRD p<0.0001; control p=0.0002). The
calculated ratio between the groups showed that PCT in a patient with ESRD was lower than the control
group (p <0.0001) given the same APACHE II score.
Discussion: Previous studies have shown that the baseline PCT level in a non-infected patient with ESRD
to be higher secondary to the chronic inflammation of uremia. However, the effect of uremia on the
immune system is complex, and leads to an overall immune deficient state and an impaired ability to
mount a proper host response.
To date, there has not been a study that compared patients with ESRD in sepsis to a control
population also in sepsis. While non-infected ESRD patients may have a higher baseline PCT, our study
shows that those in sepsis have a significantly lower PCT compared to controls.
The Prognostic Value of Additional Malignant Lesions Detected by Magnetic
Resonance Imaging versus Mammography
First Author: Alpesh K Korant, MD Benjamin Abadeer, MD, Madan Arora, MD, Trevor Singh, MD, Sunil
Nagpal, MD, David Wiese, MD, Sukamal Saha, MD.
Background: Nodal positivity has been correlated with a poorer prognosis in breast cancer (BrCA). The
addition of Magnetic Resonance Imaging (MRI) in BrCa evaluation has been shown to find additional
lesions not seen on mammogram (MMG) in up to 15% of patients (pts). However, there is no clear data
available comparing nodal positivity in pts with multiple lesions versus single lesions found on MRI and
MMG. Hence, a study was composed to compare nodal positivity in pts with single versus multiple
lesions found on MRI and MMG.
Methods: A retroprospective study of BrCa pts undergoing MRI and MMG was performed. The main
objective was to compare nodal positivity in pts with additional invasive lesions found on MRI versus
single invasive lesions found on MRI or MMG. All pts underwent sentinel node mapping with 1%
methylene blue.
Results: A total of 425 pts were included in the study. The average number of sentinel lymph nodes in
patients with single lesions was 2.46 versus 2.42 in patients with multiple lesions. The overall nodal
positivity among invasive lesions was 23.8%. The pts with single malignant lesions had a nodal positivity
rate of 21.2% versus 31.2% in pts with multiple lesions. Table I. MRI detected multiple lesions in 107 pts,
80 (18.8%) of which were not detected by MMG. Of these 80 pts, 36 (45%) were invasive, 36 (45%) were
benign and 8 (10%) were in situ lesions. The nodal positivity in pts with additional malignant lesions
detected by MRI was 47.2%. Contralateral malignant lesions were detected in 25 patients by MRI only
with 20% nodal positivity. Comparing pts with single malignant lesions to pts with additional malignant
lesions detected by MRI only, nodal positivity increased from 21.2% to 47.2% (p value < 0.006).
Conclusion: Our study confirms that additional invasive lesions found on MRI had significantly higher
nodal positivity compared with those with single invasive lesions. Hence, addition of MRI in early stage
breast cancer may have prognostic value due to increased detection of nodal positivity.
Table I. MRI and/or mammogram detected multiple vs single lesions in ipsilateral or contralateral breast
with nodal positivity in breast cancer patients:
Single Lesions
Single Breast Lesions
detected by Both MRI
and Mammogram
Multiple Lesions
Detected by
Detected by
MRI only
Number of
21.2% (57/269)
31.9% (23/72) 31.2% (29/93)
Single Lesions
Number of
Number of
20.7% (6/36)
47.2% (17/36) 31.9% (23/72)
Additional lesions Detected by MRI only
Can We Use IOP Asymmetry As a Glaucoma Screening Tool
First Author: Srinivas R Gatla, MD ( Associate) Alice L Williams, Iman A Fahmi, Daniela Monteiro de
Barros, Suneeta Dubey, R. Ramakrishnan, Rekha Khandelwal, Amitava Biswas, Atilla Bayer, Parul
Ichhpujani, Jorge F Lynch, Moataz E Gheith, Ghada A Siam, G
Purpose: To investigate the amount of intraocular pressure asymmetry in a large group of ethnically
diverse patients with and without glaucoma, and to delineate the risk for glaucoma which increasing
amounts of intraocular pressure asymmetry confer upon the patient.
Patients and Methods: Collaborative retrospective study of 326 glaucoma patients and 326 controls.
Former Wills Eye Institute fellows collected single pre-treatment measurements of intraocular pressure
on patients diagnosed as having definite glaucoma based on characteristic optic nerve damage and
confirmatory visual field damage. Patients with a normal eye examination who had normal-appearing
optic discs and no apparent glaucoma, or who had a normal eye examination in association with
refractive error or cataract, were used as controls.
Results: Intraocular pressure asymmetry is a significant risk factor for having glaucoma (OR = 2.14; 95%
CI 1.86, 2.47; p<0.001). Absence of intraocular pressure asymmetry between the fellow eyes is
associated with a 1% probability of having glaucoma. A difference of 3 mmHg is associated with a 6%
probability of having glaucoma, and a difference of greater than 6 mmHg with a 57% probability of
having glaucoma. The association between intraocular pressure asymmetry and glaucoma status is
significant for subjects with both elevated IOP (p=0.014) and statistically normal IOP (maximum IOP =21
mmHg; p<0.001).
Conclusions: Inter-eye asymmetry of intraocular pressure is a common finding in patients with
glaucoma. There is a direct relationship between the amount of intraocular pressure asymmetry
between the fellow eyes and the likelihood of having glaucoma.
Association of Body Mass Index and Colon Cancer
First Author: Alaeddin A Maeza, Muthusamy A, Jagadish K, Zakaria K, Kumar S, Manickam P
Background: Available data on the association between body mass index (BMI) and colo-rectal cancer
(CRC) differ significantly. Hence, we chose to explore the association between body mass index and CRC
in a large population-based cohort of varied ethnicities.
Methodology: National Ambulatory Medical Care Survey (NAMCS) is a national population based study
of ambulatory visits in United States. We performed a retrospective analysis of this database from 2001
to 2009. Patients were categorized into 3 different groups: BMI < 18.5; BMI between 18.5 to 24.9
(reference) and BMI > 35. Multivariate logistic regression was used to investigate the association
between BMI and CRC. Analysis was adjusted for age, gender, race, smoking and alcohol. Statistical
analyses used sample weights to determine national estimates.
Results: A weighted national estimate of nearly 251655 ambulatory medical care visits was included in
the analysis. . In the multivariate analysis, compared to patients with normal BMI, patients with morbid
obesity were 1.5 times more likely to have CRC [Odds Ratio: 1.49; 95% CI (1.17 to 1.85); p= 0.002].
Similarly, when compared with the normal group, patients who were underweight were less likely to
have CRC [OR: 0.46; 95% CI (0.36 to 0.59); p= 0.001]. On sub-group analysis, there was no significant
difference based on gender, race and ethnicity.
Conclusion: Our analysis of a large, national ambulatory cohort suggests that CRC is more likely in obese
individuals. Being underweight might actually exert a protective effect on CRC. Our findings emphasize
the strong link between increasing BMI and CRC.
Malpractice Claims of Resident Physicians in the United States
First Author: Vanessa T Pauig, MD Siva K Talluri, MD FACP Jyothsna Talluri, MD Punnaiah C Marella, MD
Anne Dohrenwend, Ph.D., ABPP Siddesh Besur, MD FACP
Introduction: Medical-malpractice is an alleged breach in standard of care that results in injury to the
patient. The objective of this study is to describe the characteristics of malpractice claims (allegations,
severity and cost of paid malpractice claims) related to resident physicians in United States from 19902010. The secondary objective is to compare resident-related malpractice claims with staff physicianrelated claims
Methods: We analyzed a retrospective cohort of malpractice claims related to resident physicians in the
United States from 1990 to 2010 included in the National Practitioner Data Bank (NPDB). We described
resident physician malpractice claims and compared them to staff physicians by frequency, severity,
category of allegation, and total payment.
Results: We included 2340 resident physician-related malpractice claims from 1990-2010. Residentrelated malpractice claims were 0.8% of all claims against physicians. Patients involved in malpractice
claims were predominantly women (54%), hospitalized (62%), and 49 years of age or younger (68%). A
total of 2340 claims was related to 2196 residents; 96% of those had only 1, 4% had 2 and 0.2% had 3 or
more malpractice payments.
The majority of claims were related to diagnosis (27%, n=628) followed by those related to treatment
(19%, n=444) and surgery (19%, n=438). The mean payment in a resident-related claim was similar to a
staff physician-related claim ($374,434 vs. $326,214 respectively; p=0.82).
Conclusion: Resident-related malpractice claims in NPDB are rare, but have payments and severity
similar to physicians. The majority of claims were related to diagnosis, treatment and surgery.
Management of Chronic Pain in an Academic Internal Medicine Clinic
April Nofzinger DO, Swathi Pullela DO, Yousif Ismail MD, Ana Capatina-Rata MD
Introduction: Opioid prescriptions have increased substantially over recent years due to growing
consensus that opioid therapy may be used for chronic non-cancer pain. The wide variance in
prescribing practices and potential for abuse has prompted the development of treatment guidelines.
The objective of this study was to determine whether analgesics were prescribed to Academic Internal
Medicine (AIM) clinic patients in compliance with opioid treatment guidelines and World Health
Organization (WHO) pain ladder.
Methods and Results: A retrospective chart review was performed on patients seen in the AIM clinic
for chronic pain from September 2010 to March 2012. Patients treated for pain secondary to cancer or
at the end of life were excluded. Patients were followed over three visits. Charts were analyzed
regarding initial medication prescribed, interventions offered, and subsequent changes in therapy at
follow up. Abuse history, risk factors for constipation, and use of a pain contract were also evaluated.
Seventy-two charts were reviewed. Patients were predominantly female (72%) with a mean age of 52.8
years. Opioids were prescribed to approximately 42% of patients at the initial appointment. Other
medications prescribed included NSAIDs (33%), Tylenol (10%), and Tramadol (5%). The percentage of
patients on opioids at follow up remained unchanged. Abuse history, risk factors for constipation, and
inclusion of a pain contract were rarely addressed.
Conclusion: Opioid prescribing practices in the AIM clinic are not in accordance with current treatment
guidelines or the WHO pain ladder. This can be improved by increased resident awareness and
education through focused didactic sessions.
The Role of Positron Emission Tomography - Computed Tomography (PET/CT) in
the Prognosis of Patients with Non Small Cell Lung Cancer (NSCLC)
Tesfaye A (Associate), Mozayen M, Sarangi M, Nagpal S
Introduction: Use of PET/CT scanning in patients with NSCLC is a current standard of care for
pretreatment staging. 18-fluoro-2-deoxyglucose (FDG) maximum standard uptake values (SUVmax) are
indicators of metabolic activity of the cancer. There are conflicting data about the prognostic
significance of PET/CT SUVmax of NSCLC patients. The objective of our study was to evaluate the
prognostic significance of SUVmax in patients with NSCLC.
Methods: A retrospective review of patients diagnosed with NSCLC between 2004 and 2008 was done.
Patients with additional malignancies, no pretreatment PET/CT scan, survival < 3 months and no followup data were excluded. Kaplan Meier and Cox proportional hazard model were used to study survival.
Results: Of the total 106 patients, females were 53 (50.5%). The median age of the study population
was 70 years. Adenocarcinoma and squamous cell carcinoma were seen in 61 (58.1%) and 44 (41.9%)
patients respectively. Nodal disease was seen in 40% of patients, while distant metastatic disease was
seen in 19% of patients. The median overall survival for patients with SUVmax<8.3 was 28.7 months
compared to 16.5 months for patients with SUVmax >8.3 (P<0.0001). Independent predictors associated
with worse survival were: Male gender (HR=1.923 [95% CI: 1.107-3.339], P=0.02); SUVmax>8.3 (HR=
2.253 [95% CI: 1.256-4.040], P=0.006); Tumor size (HR=1.780 [95% CI: 1.440 -1.983], P= 0.005), Nodal
disease (HR=2.347 [95% CI: 1.237-4.457], P= 0.009); and metastases (HR=7.189 [95% CI: 3.135-16.484],
Conclusion: Our study shows high SUVmax of the primary tumor is associated with worse survival and
could be used as a prognostic factor in stratifying patients with NSCLC.
First Author: Karna K Sundsted, MD, Caroline Grady, M.D., Molly Feely, M.D., Karen Mauck, M.D., MSc.,
INTRODUCTION: There are no specific recommendations on how to best manage the timing of surgical
intervention in patients with hip fracture who are on clopidogrel. Wide practice variation exists with
respect to the timing of surgery, and current data is limited on the safety of hip fracture surgery in this
population. We sought to compare perioperative bleeding and mortality outcomes of patients who were
taking clopidogrel compared to those who were not at the time of hip fracture surgery.
METHODS: In a historical cohort study with a 2:1 matched comparison cohort, we analyzed outcomes
of hip fracture surgery in patients on clopidogrel versus those who were not. The population was
defined as all adult patients who presented to a single tertiary care institution for surgical repair of hip
fracture between 1996 and 2010. Patients with pathologic hip fractures were excluded. The study
cohort included all patients from the study population who were taking clopidogrel at the time of hip
fracture. The comparison cohort included 2 controls per index case matched for age, sex, ASA score and
surgery date. Primary outcomes were perioperative bleeding and 30-day all-cause mortality. Secondary
outcomes were factors potentially related to perioperative morbidity such as differences in time to
surgery, cardiovascular events, thromboembolic events and reoperation rate.
RESULTS: The study cohort included 121 patients (median age 81.3 years). The control cohort included
242 patients (median age 81.5 years). There were no statistical differences between the study and
control cohorts with respect to age, gender, race, ASA score, type of fracture, anesthesia type,
thromboprophylaxis or admission hemoglobin. At baseline, the clopidogrel cohort had more patients
with a previous coronary stent vs the control cohort (28% vs 7%, p<0.001) and more patients taking
aspirin (66% vs 52%, p = 0.013). Fewer patients in the clopidogrel cohort were using warfarin at baseline
compared to controls (7% vs 17%, p=0.007) There were no statistically significant differences in
hemoglobin nadir [RR 1.59 (95% CI 0.44-5.83)], major bleeding events [RR 1.06 (95% CI 0.49-2.31)] or
transfusion requirements [RR 1.40 (95% CI 0.91-2.15)] between the two cohorts. These findings were
similarly non-significant when only considering the subset of patients who were not taking warfarin at
baseline. There was no statistically significant difference in mortality between cohorts [HR 1.14 (95% CI
0.87-1.50)]. Both cohorts underwent surgical intervention for hip fracture within an average of 36 hours
from admission. There were no differences between the two groups with respect to cardiovascular
events, thromboembolic events, postoperative infection or reoperation rates.
CONCLUSION: The results of this study suggest that prompt surgical management of hip fracture in
patients on clopidogrel can be performed without altering perioperative bleeding risk or all-cause
mortality and is not associated with excess morbidity.
Spontaneous Coronary Artery Disease and Fibromuscular Dysplasia--A Prospective
Consecutive Series with Extracoronary Vascular Imaging
Megha Prasad, Jackson Liang, Marysia Tweet, Sharonne Hayes, Rajiv Gulati, Terri Vrtiska,
Background: Spontaneous coronary artery disease (SCAD) is an uncommon cause of acute coronary
syndrome with a strong predilection for young, healthy women. SCAD has been reported in patients
with extracoronary vascular abnormalities (EVA) such as fibromuscular dysplasia (FMD), but the
phenomenon is incompletely understood. We aimed to assess the association between SCAD and EVA.
Methods: We prospectively analyzed and screened 37 consecutive patients with a SCAD history
presenting for outpatient evaluation at Mayo Clinic, Rochester MN between 6/2011 and 10/2012 with a
computed tomography angiography protocol (CTAPr), involving CTA of the neck, chest, abdomen and
pelvis (NCAP). An additional 15 patients between 3/2004 and 9/2012 were not screened with the CTAPr,
but received imaging with CTA or magnetic resonance angiography of at least one anatomic region
(NCAP). Images were interpreted by a vascular radiologist for presence of EVA.
Results: Over two-thirds (34/52) of SCAD patients with any vascular screening had EVA. Of 37 patients
evaluated with CTAPr, all were female with an average age of 44.6 years. None had previously identified
EVA. Only eleven percent had hypertension, 22% had hyperlipidemia, and 14% had smoked. 30% had
experienced at least one SCAD recurrence. Of 15 patients with limited screening, the average age was
49.7 years, 2 were male, 4 had hypertension, 5 had hyperlipidemia, 2 had smoked, 1 had known EVA,
and 4 had SCAD recurrence.
EVA were present in 62% (23) of the CTAPr cohort. Most common arteries involved were the iliac (FMD,
dissection or dilatation in 32%), visceral (FMD or dilatation in 27%), and carotid (FMD or dissection in
24%) arteries. Eleven percent had aortic tortuosity. Seven of eleven patients with SCAD recurrence had
Eleven of fifteen patients with limited anatomic screening also had EVA: 4 with visceral FMD or
dilatation, 3 with carotid FMD or dissection, 3 with iliac FMD, and 1 with aortic dissection.
Conclusions: Our data suggest the majority of patients with SCAD have coexisting EVA, including FMD.
SCAD may be a manifestation of underlying systemic vascular disease, and radiographic screening may
aid in further diagnosis and management.
Impact of Obesity on ex vivo cytokine production in rheumatoid arthritis
First Author: Melissa A Wells, MD John M Davis III, Cynthia S Crowson, Abigail B Green, Keith L Knutson,
Michael A Strausbauch, Terry M Therneau, and Sherine E Gabriel
Introduction: In persons with rheumatoid arthritis (RA), obesity is associated with negative impact on
functional status and treatment response. Adipose tissue produces a number of proinflammatory
mediators, which may modulate T-cell function. The purpose of this study was to determine the impact
of obesity on ex vivo cytokine production in subjects with RA.
Methods: We performed a cross-sectional analysis of data from a population-based cohort study of
subjects with RA and healthy controls. Data collection included age, sex, body mass index (BMI), Creactive protein (CRP), smoking status, and status for rheumatoid factor and anti-CCP antibodies.
Additional information gathered from participants with RA included RA duration, health assessment
questionnaire disability index, and medication use. Isolated peripheral blood mononuclear cells (PBMC)
were stimulated with anti-CD3/anti-CD28 to induce immune response. The cell culture supernatants
were analyzed for expression of 17 cytokines using multiplexed immunoassays. Obesity was defined as
BMI = 30 kg/m2. Spearman methods were used to examine correlations between cytokine
concentrations and BMI, adjusting for patient characteristics.
Results: Our patient population included 325 RA (128 obese), and 60 non-RA (21 obese) subjects. NonRA obese subjects were significantly younger than non-RA, non-obese subjects (mean 65 vs 70 years; p=
0.026). Other characteristics were similar between obese and non-obese. Interestingly, using antiCD3/anti-CD28 for PBMC stimulation yielded different cytokine expression in obese compared to nonobese subjects, both in patients with and without RA. Obese RA subjects produced more IL-2, IL-4, IL-10,
IL-12, IL-13, IFN-?, MIP-1ß, and TNF-a, than non-obese RA subjects. In control population, obese subjects
produced more IL-1ß, IL-6, IL-10, IL-12, MIP-1ß, and TNF-a than non-obese.
Conclusion: Obesity augmented the expression of cytokines following T-cell activation in persons with
RA in a manner distinct from control subjects. Thus, obesity may produce an inflammatory milieu
capable of inciting immune activation and thereby exacerbate disease activity in RA. Future research of
the interactions of obesity with immune activation in this disease could lead to new targets for
treatment and ultimately improve outcomes for patients with obesity.
Venous thromboembolism prophylaxis for medical patients: Implications for a
standardized order set
Daryn Collins, MD MPH
Introduction: Each patient that is admitted to Regions Hospital in St. Paul, MN, is evaluated for risk of
venous thromboembolism (VTE). Based on the degree of risk, a patient receives mechanical prophylaxis,
chemical prophylaxis, both, or neither. The current admission order set utilizes the Institute for Clinical
Systems Improvement (ICSI) guidelines to determine degree of risk. Using the newest guidelines,
published in the journal Chest in 2012, which make use of the Padua Prediction Score, we set out to
determine if Regions Hospital is over or under utilizing chemical prophylaxis for VTE.
Methods: A chart review was performed on patients admitted to a general medicine or critical care
service at Regions Hospital (St. Paul, MN) from February 1, 2012 to March 31, 2012. Risk factors for VTE
were tabulated based on the Padua Prediction Score for each patient. It was noted if the patient
received VTE prophylaxis (mechanical, chemical or both). The type of chemical prophylaxis was
recorded (unfractionated heparin, enoxaparin, dalteparin, fondaparinux or warfarin continued from the
outpatient setting). Data analysis was performed comparing those patients in high risk vs. low risk
groups, as defined by the Padua Prediction Score.
Results: Four hundred and eighty-six patients were admitted to a general medicine or critical care
service at Regions Hospital during the aforementioned time period. Patients were then excluded from
further analysis if they were admitted to the intensive care unit or if they were on chronic
anticoagulation. Final analysis included 322 patients. High risk for VTE was defined as a score greater
than or equal to four based on the Padua Prediction Score. Of the 322 patients, 269 were considered
low risk. One hundred forty of these patients (52%) did not receive chemical prophylaxis, while 129
patients (48%) did receive chemical prophylaxis. Fifty-three patients met high risk criteria. Eighteen of
these patients (34%) did not receive chemical prophylaxis, while 35 (66%) did.
Conclusion: A significant number of patients who were considered low risk for VTE, based on the Padua
Prediction Score, received chemical prophylaxis. This may have implications for modification of the
current hospital order set and for significant cost savings.
Transaminitis in Newly Arrived Refugees to Minnesota
Malini DeSilva, MD/MPH, Ann Settgast, MD/DTM&H, Christopher Anderson, MPH, Jose Debes, MD,
William Stauffer, III, MD/MSPH/DTM&H
The Minnesota Refugee Health Assessment is a clinical evaluation performed within 90 days of entry to
the U.S. to identify health issues in refugees. More than 95% of newly arriving refugees in Minnesota
undergo this examination. HealthPartners Center for International Health (CIH) in Saint Paul, Minnesota,
provides care for many newly arrived refugees.
Since 2008 Burmese and Bhutanese Nepali refugees have been two of the largest refugee groups
arriving in Minnesota. There is limited published data examining the health status of this group,
however a recent study of Karen refuges in Australia showed elevated ALT in 16.1% of patients using an
upper limit of normal of 40U/L. Unpublished observations from health practitioners at CIH suggest there
are a significant number of new Bhutanese and Burmese refugees who have asymptomatic, mild
elevations of ALT and AST discovered during new arrival screening.
We performed a retrospective cohort study of refugees presenting for new arrival screening between
5/1/09 and 9/30/11 at CIH to evaluate for any significant differences between refugee groups during
initial health assessment and if present to explore possible associations related to asymptomatic
transaminitis. This study was approved by the HealthPartners Research Foundation with a waiver of
informed consent due to the retrospective data collection and large study size. Demographic and clinical
data obtained during initial new arrival screening were extracted and audited to ensure accuracy.
Statistical analysis was performed using SAS v9.2.
There was a statistically significant difference of ALT levels between groups with prevalence appearing
to be much higher in the Bhutanese Nepali and Karen/Karenni/Burmese groups than all other refugee
groups. In addition to ethnic associations, multivariate analysis showed associations between increased
BMI, male gender, and hepatitis B infection with transaminase elevation. Hypothesized etiologies of
transaminitis include alcohol use in refugee camps and lack of access to alcohol when arriving in
Minnesota with slower degradation of ALT than AST, a viral hepatitis not routinely screened for in new
arrivals, the administration of Hepatitis B vaccination given in refugee camps prior to departure,
nutritional deficiency, or environmental/toxin exposures in refugee camps. Further analysis of collected
data and future prospective analysis will help further elucidate the etiology and clinical implications of
this transaminitis.
Resident Academic Performance and Patient Outcomes During Code Blues and
Rapid Responses Are Similar Despite Implementation of New ACGME Duty Hours
First Author: Dominique J Pepper, MD Co-Authors: Michelle Schweinfurth, Vincent E. Herrin, MD
Background: From July 1 2011, new ACGME duty hours were implemented nationwide in the United
States. This study aimed to determine whether new duty hours achieved the intended goals of excellent
patient care and improved resident learning.
Methods: Retrospective cohort study of two 12-month periods (July 2010 to June 2011; July 2011 to
June 2012) at an academic hospital. For patient outcomes we used the hospital registry for code blues
and rapid responses to compare the proportion of deaths and transfers to an intensive care unit. For
resident learning we compared percentile scores for annual in-service training examinations.
Results: 656 events occurred during the 24-month period: 187 code blues and 469 rapid responses. 48
(7.3%) deaths, 374 (57.0%) transfers to the intensive care unit and 234 (35.7%) stabilizations on the
floor were recorded. No significant differences were observed before and after implementation of new
duty hours. Of all transfers to the intensive care unit, the proportion with a code blue decreased after
implementation of new duty hours (36% [63/174] vs. 25% [49/200], P=0.017). This finding was
confirmed in multivariate regression analyses (adjusted OR= 0.59, 95%CI: 0.37-0.92). The significant
increase in percentile score (P<0.001) for resident in-service training examinations after implementation
of new duty hours (2010 to 2011) was similar to previous years (2009 to 2010).
Conclusion: Resident academic performance and patient outcomes during code blues or rapid responses
are similar despite implementation of new duty hours. However, we did observe a reduced proportion
of transfers to the ICU with a code blue. Larger, multi-center trials are needed to corroborate these
findings. Strategies are needed to improve patient outcomes during code blues and rapid responses.
Adiposity Trajectories and Global Cognitive Function in African Americans
First Author: Alycia Cleinman, MD Seth Lirette MS, Michael E. Griswold PhD, Steven T. Turner MD,
Patricia Peyser PhD, Lawrence Bielak DDS MPH, Thomas H. Mosley Jr. PhD, B. Gwen Windham MD MHS
Introduction: The association between adiposity and cognitive decline may vary by type of adiposity,
with limited data in African Americans (AA) despite AAs being disproportionately affected by dementia
and obesity. This study aims to describe relationships between cognitive decline and trajectories of body
mass index (BMI) and waist circumference (WC) over time in AAs.
Methods: The Genetic Network of Arteriopathy (GENOA) study follows a well-characterized cohort of
hypertensive individuals and their siblings (n=3437, 66% female, 57% AA, age 28-91y, 52% obese, 73%
hypertensive at baseline). Two cognitive assessments were conducted in subsequent ancillary studies,
the GENOA-Genetics of Microangiopathic Brain Injury (GMBI, n=1482 AA, hereafter called Visit 2) and
the GENOA-Coronary Calcification Study (n=752 AA, Visit 3 hereafter), about 7 years apart. Global
cognitive function was measured using the Mini-Mental State Examination (MMSE; range 0-30). Linear
regression with GEE techniques accounting for clustering were used to examine relationships of MMSE
declines as a function of adiposity trajectories adjusting parsimoniously for age, sex and education.
Results: BMI increases were associated with MMSE declines; cross-sectional effect ß=-0.21 (-0.35,-0.07)
p=0.003 for each 5 kg/m2 BMI increase between participants, and longitudinal effect ß=-0.91 (-1.38,0.45) p<0.001 for each 5 kg/m2 BMI increase within a participant. Similarly, WC increases were
associated with MMSE declines; cross-sectional effect ß=-0.20 (-0.33,-0.07) p=0.003 for each 10cm WC
increase between participants, and longitudinal effect ß=-0.66 (-1.03,-0.28) p=0.001 for each 10cm WC
increase within a participant.
These findings support that both central (WC) and overall (BMI) obesity may contribute to cognitive
decline in AA at high risk for cardiovascular disease. Future work should focus on examining the
interplay of adiposity with additional risk factors and detailing the biologic pathways by which adiposity
affects cognition.
Sildenafil Protects against Acute Kidney Injury and its Deleterious Cardiac effect;
Possible Role of Vascular Endothelial Growth Factor (VEGF)
Arnaldo Lopez-Ruiz, Andrea Soljancic, Kiran Chandrashekar, Luis A. Juncos
Introduction: Acute kidney injury (AKI), a common complication of critically ill patients, is associated with
systemic inflammation and endothelial dysfunction which promotes acute cardiac dysfunction. This is
described as “type 3 cardiorenal syndrome”. AKI results in impaired cytoprotective response as shown
by lower expression of cGMP and VEGF. Sildenafil (Sil) enhances nitric oxide actions by blocking the
degradation of cGMP. Clinically, Sil is beneficial in primary pulmonary hypertension and erectile
dyfunction by improving endothelial dysfunction. However, its role in AKI is unclear.
Hypothesis: We tested whether Sil protects against Ischemia/reperfusion (I/R) induced AKI and its
subsequent cardiac sequelae by increasing cGMP levels. We further evaluated if this protection is
associated with induction of pro-angiogenic factor (VEGF).
Methods: Male SD rats (n=6/group) were randomized into 4 groups, 1) Sham, 2) Sham+Sil, 3) AKI, 4)
AKI+Sil. AKI was induced by I/R, through bilateral renal pedicle clamping for 40min. Sil was given orally
by gavage at 20 mg/kg/d, starting 3 days before inducing AKI and continuing for 3 days after the renal
insult. During follow up, plasma creatinine (pl-creat), plasma soluble VEGF receptor (sFlt-1)
[antiangiogenic factor] and urine excretion of Neutrophil-Gelatinase-Associated Lipocalin (NGAL)
[proximal tubule injury marker] were measured. The rats were sacrificed and the kidneys and heart
collected to estimate pro-inflammatory cytokine (TNFa), cardiac stress (pro-BNP), and cytoprotective
factors [VEGF, cGMP expression] using high sensitive Elisa kits.
Results: AKI reduced cGMP levels in the kidneys (0.25±0.02 vs. 0.95±0.03 ng/ml) and heart (0.42±0.05 vs.
0.82±0.02 ng/ml) compared to shams. AKI also increased BNP in cardiac tissue (3.9±0.3 vs. 0.3±0.05
ng/ml) and renal and cardiac TNFa expression (86±5 vs. 4.8±0.7 and 54±6 vs. 4.1 ± 0.7 pg/ml
respectively). However, rats with AKI that received Sil had lower renal dysfunction [pl-creat decreased
from 2.6±0.2 to 1.6±0.1 mg/dl] and tubular injury [NGAL decreased from 2940±51 to 2020±44 UI/ml]
compared to untreated rats. Sil attenuated renal and cardiac TNFa (86±5 vs. 36.2±4.2 and 54±6 vs.
28.7±7.5 pg/ml respectively), and blunted myocardial BNP expression (3.9±0.3 to 2.1±0.2 ng/ml).
Moreover, AKI increased sFlt-1 levels and resulted in 73% and 80% reduction in renal and cardiac VEGF
expression, which was improved with Sil by 37% and 24% respectively. Additionally, Sil reduced
circulating sFlt-1 by 70%.
Summary: AKI results in renal damage and dysfunction and promotes myocardial inflammation that may
contribute to cardiac stress. Additionally, AKI attenuates the systemic expression of cytoprotective
factors (cGMP & VEGF) and stimulates the release of antiangiogenic factors. All these abnormalities
observed during AKI were attenuated by Sil.
Conclusion: Sil protects against AKI and its deleterious cardiac effect by increasing cGMP levels and by
improving the bioavailability (reduction in sFlt-1) and expression of VEGF. A potential therapeutic aspect
which arises from our study is the possibility of pre-treating patients undergoing cardiac bypass or IV
contrast with sildenafil to prevent AKI.
The Modified Early Warning Score is a Useful Tool to Diagnose Hyperglycemic
Emergencies and Predict Mortality in Resource Limited Settings
Dominique J. Pepper, Porcia Williams, Demondes Haynes
Introduction: Life-threatening hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and
hyperosmolar hyperglycemic state (HHS) require intravenous insulin therapy, while hyperglycemia with
dehydration (HD) generally does not. In resource-limited settings, early referral for intravenous insulin
therapy is impaired by inability to measure acidemia and serum osmolality. We proposed that a simple
bedside tool based on five physiological parameters may aid in rapid triage of hyperglycemic
emergencies that require intravenous insulin therapy.
Objectives: To assess the performance of the Modified Early Warning Score (MEWS) in 1) determining
the need for intravenous insulin therapy, and 2) predicting mortality in patients with hyperglycemic
Methods: Design, setting, patients. A prospective observational study conducted in an Emergency Unit
in a semi-rural district hospital in Cape Town, South Africa. Patients who met the American Diabetes
Association criteria for hyperglycemic emergency were enrolled. At initial assessment, five physiological
parameters used in the MEWS were measured: systolic blood pressure, pulse rate, respiratory rate,
temperature and level of consciousness. Main outcome measures. The performance of a pre-defined
MEWS algorithm (Figure 1) was evaluated. Predictors of mortality were assessed using regression
Results: In 125 patients with hyperglycemic emergency – DKA (n=67), HHS (n=26) and HD (n=32) – the
utility of the algorithm was fair: Sensitivity was 94%, specificity was 46%, positive predictive value was
84% and negative predictive value was 71% (Figure 1). When patients with HHS were excluded from
analyses, sensitivity improved to 100% and specificity remained at 46%. 10 (8%) of 125 patients died. In
multivariate analyses, only an increasing MEWS (OR=1.63, 95%CI: 1.11-2.40) was significantly associated
with increased mortality (Table 1). Measures of acidemia were not significantly associated with
Discussion: In a resource-limited setting, where rapid triage and referral for definitive therapy is
necessary, the performance of our MEWS algorithm as a screening tool was fair. In those with negative
serum ketones and a MEWS of 0 – 3, we advise that serum osmolality be measured in order to
discriminate HHS from HD. An increased MEWS predicts mortality in those with hyperglycemic
Effect of a nurse transitional care team on hospital readmissions at a tertiary care
Youngjee Choi, Margie Olsen, Clay Dunagan, John Lynch, Victoria Fraser, Sandra Graff, Jackie Reed,
Melvin Blanchard Washington University School of Medicine, Saint Louis, Missouri
Introduction: Medicare spends 17.4 billion dollars annually on readmissions. Previous studies of elderly,
disease-specific populations, or those under managed care plans have demonstrated decreased
readmissions when transitional care was improved. The current study was conducted in an urban,
tertiary medical center in Saint Louis, to assess whether a comprehensive transitional care program
would reduce general medicine readmissions at 30 and 90 days, and to identify factors associated with
Methods: This study was a prospective, randomized controlled trial of participants enrolled either to a
nurse transitional care team or to standard care. Prospective participants, admitted for one of four
medical conditions (acute myocardial infarction, heart failure, chronic renal failure, and chronic
obstructive pulmonary disease), with either Medicare or Medicaid, were enrolled. The intervention
consisted of nurses meeting with participants during hospitalization, providing participants with a
personal health record, discussing post-hospitalization follow-up and emergency plan, and reinforcing
the discharge medication regimen. Nurses visited participants at home within 48 hours of discharge and
as needed up to 45 days post-discharge to review discharge instructions, reconcile medications, and
facilitate transportation to physician visits. Participants also received weekly telephone calls. The
primary outcome was hospital readmission within 30 days, with secondary outcomes of hospital
readmission within 90 days and emergency department visits within 30 and 90 days.
Results: 412 participants were analyzed. Baseline demographics showed 79.9% of participants were
African American, with a mean age of 65. The nurse transitional care team led to no significant
difference in hospital readmissions or emergency department visits within 30 or 90 days compared to
standard care. Of the total 175 participants readmitted within 90 days, 33 (18.9%) participants were
readmitted within 7 days. In multivariate analysis, length of index hospital stay, number of discharge
medications, and having primary care providers that serve predominately low-income and medically
underserved individuals were significantly associated with increased readmissions at 30 days (p < 0.05).
Being a single male was additionally associated with increased risk of hospital readmission within 90
days (p = 0.01).
Conclusion: The nurse transitional care program was not effective in reducing hospital readmissions or
emergency department visits at 30 or 90 days in an urban, tertiary medical center. Our participants were
insured through Medicaid or Medicare and were primarily African American. Serving this urban
population may have come with cultural and social challenges to providing effective health care (e.g.,
low health literacy) that could not be addressed by a transitional care model alone.
Effects of Tiplaxtinin Eluting Stents on Vascular Remodeling in Porcine
Angioplasty Model
Mayank K Mittal, Tammy Strawn, Jan Ivey, Douglas K Bowles, William P Fay
Introduction: Elevated plasma PAI-1 levels contribute to the pathogenesis of atherothrombosis. Our in
vitro data suggest that Tiplaxtinin, a pharmacological inhibitor of PAI-1, inhibit migration of vascular
smooth muscle but not endothelial cell. Thus, having the potential to address the limitations of currently
available DES. Therefore, we wanted to study the effect of Tiplaxtinin coated stents on vascular
remodeling in porcine coronary artery model.
Methods: We randomly implanted 29 porcine coronary arteries with stainless steel stents coated with
polylactic-co-glycolic acid only, vehicle coated stents (VCS, n=10) or Tiplaxtinin eluting stents (stents
coated with polymer and 1mM or 10mM solution of Tiplaxtinin, TES-1, n=10 or TES-10, n=9
respectively). Stents were sterilized with ethylene oxide. Balloon was inflated 1.1 x vessel diameter
estimated angiographically. Pigs were fed aspirin until euthanization on day 21. Morphometric analysis
of vessel embedded in plastic, sectioned with tungsten-carbide blade and stained with Elastin was
performed by blinded physician researcher. Results are expressed as mean ± SEM.
RESULTS: Schwartz histopathological injury score was significantly higher in TES10 (1.96 +/- 0.26;
p=0.03) group as compared to TES1 (1.17 ± 0.25) or VCS (1.22 ± 0.18). One way ANOVA analysis of
morphometric data obtained from VCS, TES-1, TES-10 sections yielded similar lumen area (1.79 ± 0.28 vs
1.26 ± 0.25 vs 1.76 ± 0.28 mm2, p=0.3), similar neointimal area (1.19 ± 0.27 vs 1.24 ± 0.19 vs 1.71± 0.28
mm2, p=0.3) and percent luminal stenosis (40.41 ± 5.35 vs 54.97 ± 7.0 vs 52.01 ± 7.42 % vs, p=0.2), but
the mean intimal thickness was significantly more in the TES 10 group (0.18 ± 0.03 vs 0.23 ± 0.03 vs 0.31
± 0.05 mm, p=0.03).
Conclusion: Tiplaxtinin eluting stents do not attenuate neointimal thickening following implantation in
porcine coronary arteries, but may even have an opposite effect. Injury scores have been previously
demonstrated to be directly proportional to neointima formation, which may explain our findings.
However, potential negative vascular remodeling due to Tiplaxtinin’s biological effect could not be
excluded, and warrants further investigation.
Opioid prescription practices among internal medicine residents in ambulatory
care setting
Hariharan Regunath, MD Kelly Cochran Pharm D BCPS James Shortridge MD Daniel Kim MD Syed Akbar
MD Boshard Barbara BSN, MS, RN Rebecca Chitima-Matsiga MS MPH1 Jyotsna Reddy MD James P Koller
Introduction: Prescribing opioids for chronic non-cancer pain (CNCP) has been a challenge due to risks
from abuse, addiction, tolerance, adverse effects and medication interactions.
Methods: A cross sectional survey of internal medicine categorical residents was done in April and May
of 2012. This was designed and developed by residents and reviewed by internal medicine faculty to
assess internal medicine residents’ knowledge, attitude and practices toward managing chronic noncancer pain (CNCP) in ambulatory setting. We used the WHO definition for CNCP which is defined as
pain persisting for more than 3 months and not related to an underlying malignancy. The survey
included demographic details, the number of patients seen, those causing concern, the reasons for
concern and 12 Likert-style questions to assess knowledge, attitude and practices towards prescribing
opioids for CNCP.
Results: Of the 45 respondents (45/49, 92% response rate, M:F=30:15. 33.3%(15/45) were PGY1s,
35.6%(16/45) were PGY2s and 31.1%(14/45) were PGY3s. Among them, 80% (36/45) reported seeing
more than one patient with CNCP in the previous 3 months; 62.2% (28/45) had at least one patient
causing concerns from misuse and addiction; 73.3%(33/45) reported lack of access to pain specialist;
77.8% (35/45) reported a lack of training in the management of CNCP; 86.7% (39/45) reported a lack of
consistent documentation and treatment method among different providers and 82.2% (37/45) were
uncomfortable in prescribing refills for patients of other providers. All (100%, 45/45) consulted the
clinical pharmacist for either of dosage adjustment, opioid conversion or patient education; 86.7%
(39/45) agreed that continuing medical education would benefit them with preference to either inservice presentation or case based discussion.
Conclusions: Our survey demonstrates that internal medicine residents do have deficits in their ability
in managing patients with chronic non-cancer pain. Continuing medical education either through inservice presentation or case based discussions will be important. Also, the development of a
standardized algorithmic approach for risk assessment, opioid prescription, and documentation will help
to improve opioid prescription practices.
Clostridium Difficile Infection in Hospitalized patients with Leukemia: A
Nationwide Analysis
First Author: Ruihong Luo, MD
Background: The incidence of Clostridium Difficile infection (CDI) is increasing among hospitalized
patients. CDI is associated with antibiotic use, acid suppression, and hospitalization, all of which occur
frequently in leukemia. Our objective was to investigate the association of CDI with the clinical
characters and outcomes of hospitalized leukemia patients.
Methods: All adult cases (age over 18) with primary diagnosis of leukemia or diagnosis of CDI on
discharge were extracted from the United States Nationwide Inpatient Sample (NIS) 2009 database.
They were identified by ICD-9-CM codes. The primary outcomes were the impact of CDI on mortality,
length of stay and charges. The secondary outcome was the independent risk factors of CDI in
hospitalized patients with leukemia. A regression analysis was used to derive odds ratios (ORs) adjusted
for potential confounders.
Results: A total of 30,197 discharges with primary diagnosis of leukemia were identified through the U.S.
in 2009. The prevalence of CDI in leukemia patients was 4.3%, which was much higher than that of nonleukemia patients (0.8%). Patients with acute leukemia had higher prevalence of CDI than chronic
leukemia (4.8% vs. 1.9% in acute lymphoblastic leukemia vs. chronic lymphoblastic leukemia, P<0.001;
5.4% vs. 2.4% in acute myeloid leukemia vs. chronic myeloid leukemia, P<0.001). CDI was associated
with longer length of hospitalization and higher total hospital charge in leukemia patients. However, we
found that CDI had no significant impact on the in-hospital mortality. In addition, female patients had
higher prevalence of CDI than male patients (OR=1.17), but gender didn’t significantly affect the
mortality. Older age was associated with in-hospital mortality but was not an independent risk factor of
CDI in leukemia patients. Patients with race of Asian/pacific islanders and Native American had a higher
prevalence of CDI comparing with Caucasian (OR=1.48 and 1.87 respectively). The high comorbidity
Charlson’s index was associated with increased mortality but had no impact on prevalence of CDI.
Pneumonia was an independent risk factor of both CDI and mortality (OR=1.68 and 2.40 respectively).
Patients in urban teaching hospital had higher prevalence of CDI and higher in-hospital mortality
(OR=2.18 and 1.45 respectively). Patients in northeast and west have higher prevalence of CDI (OR=1.37
and 1.27 respectively), but the in-hospital mortality of leukemia patients didn’t have any significant
difference across the country. Therapy with marrow transplant was associated with higher prevalence of
CDI (OR=2.69) but lower in-hospital mortality (OR=0.86).
Conclusions: Patients with leukemia have higher prevalence of CDI than non-leukemia hospitalized
patients. In-hospital CDI is associated with longer hospital stay and higher hospital charges for leukemia
patients, but it has no significant impact on in-hospital mortality. Pneumonia is significantly associated
with CDI. Female patients, patients in urban teaching hospital and patients in the region of northeast
and west have higher risk for developing CDI. Treatment with marrow transplant is associated with
higher prevalence of CDI but lower mortality for patients with leukemia.
Diagnostic utility of CTA chest in “PE unlikely” patients
Kasaiah Makam MD, Ashok Akula MD, Nirmal Sunkara MD, Alan Greenberg MD
Introduction: Acute Pulmonary embolism (PE) affects approximately 69 persons per 100,000 people
annually and is a major problem if not diagnosed in timely fashion. Computed tomography angiography
(CTA) is equivalent to conventional angiography in diagnosing acute PE. Modified Wells score stratifies
the patients at risk of acute PE into PE likely (score>4) and PE unlikely (</=4) groups. D-dimer level <500
mcg/ml by ELISA essentially rules out acute PE. The combination of a score </=4.0 and a negative DDimer result may safely exclude PE in a large proportion of patients with suspected PE. We and others
have observed frequent utilization of CTA in PE unlikely group. Therefore, we wondered whether there
was any net diagnostic utility in obtaining CTA chest in PE unlikely patients.
Methods: This was a single center, retrospective analysis based on results of CTA chest, CXR (chest xray) and chart review. Based on chart review modified Wells score was determined. Patients divided into
PE likely and PE unlikely groups. For this study, “operationally” PE likely group was defined as score >4 or
score </=4 with positive D-dimer and PE unlikely group was defined as score </=4 with negative D-dimer
if available. The presence or absence of PE was determined based on CTA chest results. Clinically
relevant alternative diagnoses (AD) made on CTAs were ascertained. CXR reports were reviewed and
compared to CTA chest results.
We calculated prevalence of PE and net diagnostic utility for CTA chest as defined below in PE unlikely
group. Prevalence of PE= Number of PE/ total CTAs performed in defined PE unlikely group.
Net diagnostic utility= (CTA AD –CXR AD)/total CTAs performed in defined PE unlikely group (CTA ADCXR AD= Clinically relevant alternative diagnosis not discernible on CXR).
Results: 268 charts were reviewed who underwent CTA chest within 24 hours of admission for ages 1865. Two patients were excluded from study (chronic PE). 16 patients were in PE likely group and 250 in
PE unlikely group. D-dimer was performed in 51 patients of 250 in PE unlikely group and 43 were Ddimer positive. Therefore defined PE unlikely group included 207 patients. In this group 3 patients had
acute PE, 7 had alternate diagnoses. Prevalence of PE was 1.44% (3/207). Net diagnostic utility of CTA
chest in PE unlikely group was 3.38% (7/207, AD=Pneumonia-3, Pneumothorax-2, Lymphoma-1, skeletal
Conclusion: Only 1 in 30 CTAs has yielded clinically useful information. Our results indicate that
performance of CTA chest in the defined PE unlikely group has little diagnostic utility. Therefore our data
does not support regular use of CTA chest in PE unlikely group. Routine incorporation of modified Wells
score and D-dimer assay in the initial evaluation of patients in whom PE is diagnostic consideration
should lead to significant decrease in CTA chest examinations.
Resource utilization in the testing of hospitalized patients with abnormal liver
Parambir S. Dulai, Rolland C. Dickson, Harley P. Friedman, Mark A. Cervinski, Richard I. Rothstein, Arifa
Background: The evaluation of abnormal liver tests (LT) in the outpatient setting follows a systematic
method. Inpatient evaluation is less structured, assumes more urgency and leads to a more liberal
approach which often involves the routine use of a panel of tests. We hypothesized that routine panelbased testing in hospitalized patients with abnormal LT may be of limited benefit and contributes to
excess cost.
Methods: Serum ceruloplasmin (CPL) and hemochromatosis genetic testing (HFE) were used as
surrogate markers for routine panel-based testing in hospitalized patients with abnormal LT (alanine
transaminase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin). Charts
of patients with CPL or HFE testing done during admission in the non-critical care setting of a tertiary
care facilitiy over a 2 year period were retrospectively reviewed for: iron studies (ferritin, serum iron,
total iron binding capacity (TIBC), % saturation), LT abnormalities, clinical indicators, consultations,
further testing, discharge diagnosis and outpatient follow up.
Results: Twenty patients underwent HFE testing. Only 16 had iron studies within 6 months of testing of
which 12 had saturations >45%. Iron saturations were falsely elevated in 11 patients due to a low TIBC
(mean: 146; reference range: 250-450mcg/dL) secondary to an active inflammatory state or poor
nutrition (mean albumin 2.7 g/dL). One patient had a true elevation in transferrin saturation. This
normalized after discharge. Ferritin was elevated in 11/12. However, 10/11 had alternative
inflammatory etiologies. All 20 were negative for C282Y mutation and 6 heterozygote positive for H63D
CPL testing was performed in 123 patients (mean age: 50 yrs; range 21-97 yrs). Testing was
recommended by consulting services 67% (82/123) of the time with gastroenterology accounting for
72% (59/82). Clinical parameters to prompt testing were present in only 22% (27/123). Abnormal LT
were recorded in 74% (91/123) of patients and 78% (71/91) had clear alternative etiologies (gallstones,
malignancy, viruses, medications, alcohol and cholangitis). Follow-up outpatient LT were done in 55
patients with normalization in 31 (56%). Low CPL levels were found in 10/123 (mean:11.6, range:3-14.6
mg/dL). One was fully evaluated with unremarkable serum copper, 24 hour urine copper and an eye
exam. CPL normalized after discharge. The other 9 were not further evaluated.
Conclusion: In our cohort of hospitalized patients, iron studies and serum CPL for evaluation of
abnormal LT were of little use and limited by confounders and false positives. A more structured
approach to the testing of abnormal LT in the inpatient setting with emphasis on prior probability of
disease or test characteristics could prevent this unnecessary testing and wasted resources. This
represents a potential area for a quality improvement intervention leading to enhanced cost effective
The Impact of Procalcitonin Biomarker on Length of Hospitalization for Patients
admitted with Pneumonia
First Author: Quang V Ton, MD Dudekonda
Studies have suggested that serum procalcitonin biomarker levels improve the ability to differentiate
between bacterial and nonbacterial infections. Previous trials have shown a reduction in antibiotic use
through clinical algorithms based on procalcitonin levels in patients admitted with pneumonia. We
conducted a study to evaluate the relationship of procalcitonin biomarker with subsequent antibiotic
administration and its impact on length of hospital admission. We hypothesized the length of
hospitalization would be decreased in patients admitted with pneumonia when the procalcitonin guided
therapy was clinically adherant.
We retrospectively reviewed electronic medical records of all patients that had a procalcitonin
biomarker level during the first nine months of availability between July 2010 and March 2011 in a single
center community hospital. Patient were included if they had a procalcitonin level measured and
radiographic evidence of pneumonia. Patients were divided into two groups based on procalcitonin
levels: discouraged or encouraged use of antibiotics. The discouraged use of antibiotics group included
patients who had a procalcitonin level of less than 0.25 ug/L (n=90); while the encouraged use of
antibiotics group included patients who had a procalcitonin level of greater than 0.25 ug/L (n=166). The
subsequent antibiotic administration and length of admission was then documented. Statistical analyses
were performed using chi-square analysis for nominal data and unpaired t test (two sided).
In the discouraged use of antibiotics group, 10 procalcitonin levels (11.1%) had antibiotics discontinued,
while in 80 levels (88.9%) antibiotics were continued. In the encouraged use of antibiotics group,
antibiotics were discontinued in 14 levels (8.4%) and continued in 152 levels (91.6%). Clinical adherence
with procalcitonin guided therapy was shown in 162 instances (63.3%) while non-adherence was in 94
instances (36.7%) in accordance with procalcitonin levels (p<0.0001). Average length of antibiotic use
was 5.5 days in the discouraged use of antibiotics group and was 6.3 days in the encouraged use of
antibiotics group (p<0.001). Average length of hospitalization was 12.8 days in the clinically adherent
group and was 16.5 days in the non-adherent group (p<0.0001)
Recent reports suggest the potential for reduction in antibiotic exposure using clinical algorithms for
antibiotic therapy decisions in patients admitted with pneumonia. Our results suggest that clinical
adherence with procalcitonin guided therapy decreases length of hospitalization. This is one of the first
studies to examine clinical adherence in terms of procalcitonin levels and antibiotics in the United
The Impact of the Economic Recession in Late 2000s on Acute Myocardial
Infarction Occurrence in Different Socioeconomic Areas of New Jersey Raritan Bay
Yulong Li, Iris Rukshin, Fangfang Pan, Shuvendu Sen, Mohammed Islam, Abdalla Yousif, Vladimir Rukshin.
Introduction: The financial crisis in 2008 started the late 2000s economic recession. The object of this
study is to assess the impact of this recession on occurrence of acute myocardial infarction (AMI) in
different socioeconomic areas of Raritan Bay region, New Jersey (NJ).
Methods: We analyzed a retrospective cohort of AMI patients that were treated at two main MI centers
in Raritan Bay region from 01/2006 to 06/2012. All cases were identified by having AMI as the primary
diagnosis at discharge. These cases were divided into two groups based on whether the adjusted annual
income (abbreviated as income) of the zip code area they resided was above or below the state average.
Student-t test was used to compare the age difference between these two groups. The differences in
gender and co-morbidities (hypertension, diabetes, and hyperlipidemia) were examined using Chisquare test. Spearman Rank Correlation test was used to examine correlation between monthly AMI
occurrence in each group and NJ unemployment rate/Dow Jones Industrial Average in the
corresponding month.
Results: A total of 1,467 cases of AMI were treated from 01/2006 to 06/2012. There were 990 AMI
patients living in the areas (average income: $44,515; total population: 187,328) with income less than
the NJ state average ($52,118), and 477 in the areas (average income: $64,138; total population: 90,013)
with income greater than the state average. Between these two groups (lower- vs. higher-income
group), the differences in age (69.5 vs. 70.1, P=0.50), gender (female/male ratio: 0.857 vs. 0.807,
P=0.58), hypertension (46% vs. 41%, P=0.07), diabetes (37% vs. 32%, P=0.09) and hyperlipidemia (38%
vs. 34%, P=0.10) were not statistically significant. In the lower-income group, monthly occurrence of
AMI trended up after onset of the recession and its increase was correlated with the rise of
unemployment rate in NJ (coefficient=0.231, P=0.042). In contrast, in the higher income group, monthly
occurrence of AMI remained stable and was not correlated with the unemployment rate (coefficient=0.02, P=0.887). No significant correlation was found between the Dow averages and the AMI
occurrences in both groups.
Discussion: Socioeconomic status of neighborhood of residence is known to be associated with
occurrence of AMI. The findings of this study suggest that the residents in lower socioeconomic areas
are at a higher risk for AMI during economic recession and that unemployment is a contributing factor.
This could be caused by several factors that may include a higher stress level and/or a decreased
compliance to treatment of comorbid conditions because of economic strain.
Elizabeth Vassallo-DeLuca, MD Co-Authors: Trent Wang, DO, Peter Ricketti, DO, Alex Tentler, MD, Neil
Kothari, MD
Abdominal Aortic Aneurysm is a dilatation in the abdominal aorta > 3 cm that results from degeneration
of the arterial wall media. AAAs occur five times more frequently in men, with increased incidence in
advanced age. Additionally smoking is the strongest independent risk factor for development of AAAs,
with dose effect up to five-fold increase. Aneurysms > 5.5 cm in diameter are at markedly increased
annual risk of rupture. Those that rupture are associated with a 50% mortality prior to reaching a
hospital, and up to an 80% in-hospital mortality for an overall mortality of 75-90%, resulting in about
14,000 deaths per year.
AAA screening has been shown to significantly reduce the morbidity and mortality associated with AAA
rupture. Screening is done by ultrasound, an inexpensive non-invasive test which detects AAA with close
to 100% sensitivity and specificity. The US Preventive Task Force Guidelines recommend one-time
screening for AAA by abdominal ultrasound in men > 65 years of age who ever smoked in their lifetime.
The guidelines recommend against routine screening in women and make no recommendation for
males who have no smoking history. Although AAA screening has been well-documented to decrease
mortality, there have been no official screening guidelines implemented in the University Hospital
outpatient setting, and there are no physician reminders in the computer system. Last year, a study was
conducted to measure resident compliance rates for screening. Of the 82 patients who met criteria and
were eligible for screening ultrasound, three had ultrasounds ordered on or before the date of clinic visit
(3.7%), and two had ultrasounds completed (2.4%). This study revealed poor AAA screening among
eligible patients, which is a consistent problem found not only in academic centers, but at the national
level too with screening compliance rates as low as 12.9% to 36% (Eaton et al., Llonze et al.). Based on
last year’s results, a study design was implemented in the form of mini lectures to increase compliance
among internal medicine residents. Three ambulatory cohorts were provided mini lectures, while two
other resident cohorts remained as a control.
After the intervention, of the 46 patients who met criteria for screening, 20 patients had ultrasounds
ordered (43.5%). In contrast, of the 20 patients who met criteria for screening in the control arm, only
two patients had ultrasounds ordered (10%). Based on these preliminary results, educational campaigns
to increase awareness of AAA screening may result in increased compliance with AAA screening. Future
interventions such as automated EMR reminders may increase AAA compliance even more until we
reach our goal of 100% compliance.
Thrombocytopenia A Risk Factor for HIV Immunological Non-Responders
First Author: Raji Shameem, MD Second Author: Pooja Kumar MD Third Author: Dana Shani MD Fourth
Author: Ladan Ahmadi MD
Introduction: A unique subset of HIV seropositive patients has emerged with the advent of antiretroviral therapy. These patients have been treated with anti-retroviral therapy and achieve successful
virological suppression but they have a blunted CD4 response. These immunological non-responders
(INR) are more likely to develop HIV related complications with increase in morbidity and mortality.
Studies have shown age and CD4 nadir to be risk factors. Thrombocytopenia is a common hematological
manifestation of HIV infection. The aim of this study is to see if thrombocytopenia is a risk factor for
becoming an HIV INR.
Methods: We conducted a retrospective study of 526 HIV patients in an urban ambulatory setting.
Platelet count, from the complete blood count at the patient’s initial visit to the clinic was obtained by
medical record review. HIV patients with a platelet count <150 x 10^9 /L were defined to be
thrombocytopenic. Immunological non-responders were defined to have viral load suppression for at
least six months, but a CD4 count <200. A viral load less than 200 via PCR testing was defined to be
undetectable. To prevent confounding factors for thrombocytopenia patients with chronic liver disease,
hepatitis B and C infections, malignancy, treatment with trimethoprim and sulfamethazole, and
chemotherapy treatment were excluded. Data was adjusted for race, sex, age, nadir of CD4 count, and
peak of viral load.
Results: From the 526 charts reviewed, 129 patients were taken out due to the exclusion criteria. Out of
the 397 patients that met the inclusion criteria, 23 patients met our criteria for being immunological
non-responders. The prevalence of immunological responders in the study population was 5.8%
(23/397). 39% (9/23) of the INR patients were thrombocytopenic at the time of initial presentation at
the clinic. The prevalence of thrombocytopenia in patients who were not immunological non-responders
was 11% (41/374). INR patients that did not have platelet counts <150 x 10^9 /L, had lower platelet
counts compared to patients who were not immunological non-responders. The average platelet count
for the INR group was 167,000. Patients that did not meet our criteria for INR had an average platelet
count of 318,000. Patients who become immunological non-responders were more likely to have lower
platelet counts at initial presentation compared to the other HIV patients in the sample population.
Conclusion: No other studies have looked at the prevalence of immunological non-responders in an
urban setting, which we found to be 5.8%. Also this study has recognized thrombocytopenia may be a
risk factor for INR with the lower initial platelet counts seen. A larger INR population group is necessary
for further analysis. We plan to include other urban settings with HIV patients in order to see if
thrombocytopenia is a true risk factor. Till then, physicians should keep in mind that thrombocytopenia
at initial presentation may be a harbinger for immunological non-response in HIV patients.
Gender based differences in Abdominal Aortic Aneurysm (AAA) Rupture: A
Retrospective Review
Srikrishna V Malayala, MBBS Paul M Anain, MD Khalid J Qazi, MD
Introduction: Abdominal Aortic Aneurysm (AAA) ruptures cause 5% of sudden deaths annually.
Traditionally, it was labeled as a disease of elderly males. There are recommendations to screen for AAA
in males over 65 years and ever smoked, but screening is not recommended in females. Women were
not a part of the studies that formulated screening guidelines, owing to the lower prevalence and
delayed age of presentation. Evidence suggests that aneurysms in females tend to rupture at a smaller
size than males and have a worse outcome compared to males. Current guidelines suggest that AAAs
should be repaired electively at 5.5 cm in males. No such guidelines are in practice for females.
Methods: The primary objective of this study is to compare the characters of ruptured aneurysms in
females and males. Secondary goal is to emphasize the necessity to formulate screening and
management guidelines for AAAs in women. Between the two teaching institutions (Sisters of Charity
and Mercy Hospitals), 119 patients were admitted with AAA rupture over the last 6 years. A
retrospective review was performed to compare the perioperative mortality and size at rupture.
Demographic characters (race, age, weight, height, smoking history), co-morbidities, medications,
aneurysm location, type of surgery, post-operative complications, length of ICU and hospital stay were
compared. SPSS v.19 was used and p-value less than 0.05 was considered significant.
Results: 68.9% of the patients were males (N=81) and 31.1% were females (N=38). The mean age of
rupture in females (82.4 years; SD=8.6) was significantly higher than in males (74.9 years, SD=13.1); pvalue=0.002. The mean size of rupture in females (7.36 cm; SD=2.09) was significantly smaller than in
males (8.13 cm, SD=1.90); p<0.05. Overall mortality in females (68.4%) was significantly more than
males (30.8%); p-value<0.001. Males were offered surgery more often (92.5 % vs 63.1%, p<0.001); age
and co-morbidities being the contra-indications to surgery in females. The mortality was similar to males
after an open repair (64.7% vs 63%); but higher after an endovascular repair (47 % vs 16.7%). The mean
length of ICU stay and hospital stay in females were 5.08 days and 14.0 days as compared to 3.89 days
and 12.8 days in males respectively, suggesting higher morbidity in females.
Conclusions: This study confirms that the morbidity and mortality of AAA rupture in females is
significantly higher than in males, in spite of lower incidence and smaller size at rupture. For a long time,
coronary artery disease remained as an under diagnosed, under treated and under researched disease
in females. A similar situation might exist for AAA in women. This study calls for a larger multi-center
trial to validate these results and formulate sex specific screening and management guidelines. Primary
care physicians should engage in closer surveillance of their elderly female patients who are at risk of
AAA rupture.
Frequency of nosocomial infections in patients receiving red cell transfusions-a
single institution experience.
First Author: Christos Fountzilas, MD All authors: Christos Fountzilas MD Ronen Harel DO Georgia
Panagopoulos PhD Randy Levine MD Robert Graham MD
Introduction: Immunomodulatory changes have been noted in patients who received red blood cell
transfusions, including infections, transfusion related acute lung injury and development of
malignancies, with most of the data coming from the surgical and trauma literature. Aim: This study
compares the frequency of nosocomial infection in patients who received at least one transfusion of
packed red blood cells (transfused group) vs. those who did not (non transfused group). Method: In this
retrospective clinical record review, patients admitted to Medicine or Cardiology in a one month period
were identified through the hospital’s admission data base. Patients with a length of stay of less than 48
hours or an infectious process documented in the initial assessment were excluded. The patients’ age,
gender, length of stay, past history of DM, malignancy, immunodeficiency, the presence of hemorrhage,
admission hemoglobin, transfusion of blood products, development of a nosocomial infection
(documented source or febrile illness responding to antibiotics) during the index admission were
recorded. SPSS was used for statistical analysis. Results: 368 (57%) of the admitted patients fulfilled the
inclusion criteria with a mean (SD) age of 70(15) years. 162(44%) were males. There were 57 (15%)
patients with transfusion of at least one unit packed red blood cells. The frequency of infections in the
transfused group was higher [20/57 (35%) vs. 31/311(10%), p
Josef Edrik Keith Bautista MD and Alexander Sy MD Department of Internal Medicine, Metropolitan
Hospital Center, New York, New York.
Vitamin D affects colononic carcinogenesis by modulation of apoptosis and by inhibition of angiogenesis.
Data on this is conflicting; several studies failed to show a clinical correlation between vitamin D levels
and the incidence of carcinomatous polyps or colon cancer. This study aims to determine whether any
association between vitamin D and carcinomatous polyps in the predominantly Latin American
population of Spanish Harlem.
METHODS: This is a case-control study of patients who underwent colonoscopy at Metropolitan Hospital
Center, with vitamin D levels taken one month before or after the colonoscopy. Vitamin D levels was the
main independent variable studied. Polyp-positive samples (CP+) were designated as the case group
while polyp-negative samples (CP-) were the control group. Logistic regression analysis was used to
estimate odds ratio at 95% confidence interval. Adjusted variables were chosen a priori and included
age, sex, race, smoking history, alcohol history, body mass index, folate and aspirin.
RESULTS: 136 patients were included in this analysis, comprised of 43 cases and 93 controls. 35% of the
samples had vitamin D levels <20 ng/ml, and 65% had vitamin D levels <30 ng/ml. In a multivariable
analysis using <20 ng/ml as the cut-off, age > 68-years-old was significantly associated with increased
odds of being CP+ (Adjusted OR: 7.93, 95%CI: 1.35, 46.47) and being male was also significantly
associated with increased odds of being CP+ (Adjusted OR: 2.81, 95%CI: 1.04, 7.59). When <30 ng/ml as
the cut-off, age > 68-years-old remained significantly associated with increased odds of being CP+
(Adjusted OR: 8.23, 95%CI: 1.41, 48.01) and being male was associated with a non-significant increased
odds of being CP+ (Adjusted OR: 2.69, 95%CI: 0.99, 7.31).
The association of vitamin D with being CP+ was not significant in univariable models for levels <20
ng/ml (OR: 0.91, 95%CI: 0.42, 1.99) or levels <30 ng/ml (OR: 1.14, 95%CI: 0.53, 2.45). In multivariable
models, the association of vitamin D with CP+ grew stronger from vitamin D <20 ng/ml (Adjusted OR:
1.04, 95%CI: 0.43, 2.52) to vitamin D <30 ng/ml (Adjusted OR: 1.58, 95%CI: 0.62, 4.04), though in neither
was statistically significant.
CONCLUSION: Being aged > 68 years and being male are associated with increased odds of being CP+.
Vitamin D levels, using two established cut-offs, are not significantly associated with increased odds of
being CP+. However, our data suggest that there may be a threshold effect of vitamin D on increasing
odds of being CP+ at <30 ng/ml.
Association Of Chronic Kidney Disease And Cardiovascular Morbidity Among
Hospitalized Patients With Systemic Lupus Erythematosus: Findings From A
National Study
First Author: Marjan Mujib, MD, MPH, Bella Mehta, MD, Nabila K Mazumder, Chandrasekhar
Palaniswamy, MD, Sahil Khera, MD, Dhaval Kolte, MD, Petros Efthimiou, MD, Ioannis Tassiulas, MD,
Wilbert S. Aronow, MD, FACP
BACKGROUND: Nearly fifty percent of all systemic lupus erythematosus (SLE) patients develop chronic
kidney disease (CKD) that manifests at some point during the natural history of disease. Most of SLE
patients die due to cardiovascular causes, however. In the current study, we investigated the association
of CKD and acute myocardial infarction (AMI) and congestive heart failure (CHF) among SLE patients
from a large nationwide hospital registry.
METHODS: We used the nationwide inpatient sample (NIS) database from the year 2010. The
Nationwide Inpatient Sample is the largest all-payer inpatient care database in the United States from
which national estimates of inpatient care can be derived. All hospitalized patients aged between 18 to
65 years included in the NIS 2010 database with a confirmed discharge diagnosis of SLE, as per the ICD9-CM code 710.0 were identified. Multivariable logistic regression was used to determine the
association of CKD with CHF and AMI among these patients. Cox proportional survival analysis was used
to determine the association of CKD and in-hospital mortality.
RESULTS: 28,175 SLE patients were identified (from approximately 8 million patients- NIS 2010). The
mean age was 45 (±13) years, 90% (25,282) were women and 57% (16,186) were non-whites. CHF was
prevalent in 8.6% (2302/26889) and 22.4% (288/1286) of patients without and with CKD, respectively
(adjusted odds ratio for CHF comparing those without and with CKD, 2.27; 95% confidence interval {CI},
1.96–2.64; p<0.001). AMI occurred in 1.3% (360/26889) and 3.0% (38/1286) of patients without and
with CKD, respectively (adjusted odds ratio, 1.53; 95% confidence interval, 1.06–2.20; p=0.023). CKD was
not associated with in-hospital mortality among hospitalized SLE patients (Table 1).
CONCLUSION: In this large national database, CKD was independently associated with AMI and CHF
among hospitalized SLE patients. Further prospective studies may be needed to elucidate this
relationship in this high-risk population.
Table 1: Association of chronic kidney disease and cardiovascular outcomes among systemic lupus
erythematosus patients
Events (%)
Unadjusted odds
Adjusted odds
(95% confidence
(95% confidence
Heart failure
3.08 (2.69–3.54)
2.27 (1.96–2.64)
38 (3.0%)
2.24 (1.60–3.15)
1.53 (1.06–2.20)
Unadjusted hazard
Adjusted hazard
(95% confidence
(95% confidence
0.79 (0.49–1.29)
0.65 (0.40–1.06)
17 (1.3%)
*Absolute risk differences were calculated by subtracting percent events in patients without CKD from
those with CKD
†Odds ratios and hazard ratios comparing patients with and without CKD
** Model adjusted for age, sex , race, coronary artery disease, valvular disease, hyperlipidemia,
smoking, diabetes mellitus, hypertension, obesity, peripheral vascular disease, atrial fibrillation, anemia,
Hepatocellular carcinoma: Ethnic Disparities in Viral Etiology: The Harlem
First Author: Yahuza Siba, MD John Jeremiah Kretchy, MD Anand Gupta MD Joan Culpepper-Morgan MD
Background: Hepatocellular carcinoma (HCC) is the most rapidly increasing cancer in the U.S. The
prevalence of hepatitis B and C in HCC in the U.S is approximately 18% and 29% respectively. Harlem
Hospital, NY serves a demographically unique community of color with 45% African Americans (AA), 35%
Hispanic Americans (HA), 10% African immigrants (AI) and 10% others.
Method: A retrospective cohort review was done to describe the epidemiology and clinical
characteristics of patients with primary HCC seen at Harlem Hospital between Jan 2000 and Dec 2010
Results: Seropositivity for HCV was 70% (32/46) and 26% (12/46) for HBV in patients with HCC. 6.5%
(3/46) were coinfected with HBV. In 4.3% (2/46) the etiology of HCC was undetermined, p<0.0005 vs.
U.S average. The average age was 61 years, range 38-85. 75% (35/46) were male. The racial background
for HBV-related HCC was 75% (9/12) AA, 8.3% (1/12) HA, and 16.7% (2/12) AI. Whereas for HCV-related
HCC, it was 75% (24/32) AA, 12.5% (4/32) HA and 12.5% (4/32) AI. HBV-related-HCC occurred at a
younger age (52 years, ±9.5 SD) than HCV-related-HCC (61 years, ± 9.4 SD), p = 0.007. 26% (8/32) HCV
patients had positive HBcAb. The prevalence of cirrhosis in the HBV group was 58.3% (7/12) and 81.3%
(26/32) in the HCV group. Thrombocytosis, which has been associated with large tumor volumes and
adverse outcome was less common in women with HCC 30% (3/10) than men 70 % (7/10) p= 0.0069 and
HBV more than HCV 33% (4/12) vs. 15.6% (5/32), p=0.0263. HCC without cirrhosis occurred in 33%
(4/12) of HBV compared to 18% (6/32) of HCV, p= 0.045. Only 26% (12/46) were followed up in the GI –
Hepatology Clinic for HCC surveillance prior to diagnosis. The mortality rates for HBV and HCV related
HCC were 83.3% and 70.3% respectively.
Conclusions: The seroprevalence of HBV and HCV in HCC was significantly higher in our cohort (26% vs.
70%) than the national average (18% vs. 29%). African Americans were over represented in our cohort
whereas Hispanic Americans were under represented. There were no Caucasians or Asians in our cohort.
The HBV related HCC patient was more likely to be young, non- cirrhotic, and have thrombocytosis than
the HCV patient. A significant proportion of HCV patients had evidence of prior HBV exposure. We
conclude that there is increased need for HCC surveillance among HBV and HCV patients in the African
American population.
Obesity impairs the efficacy of Colon cancer treatment
First author: Nischala Ammannagari MD Additional authors: Erin A. Gillaspie MD, Christine M.
Burrington, Melissa J. Horsman, Michael W.Greene PhD
Introduction: Obesity has reached epidemic proportions globally. Colon cancer is one of the leading
causes of cancer related deaths in United States and obesity is associated with one-third of incidence of
colon cancer. Obesity is also associated with a worse prognosis of colon cancer. However, the
mechanistic details are unknown and animal models to investigate human colon cancer in the setting of
obesity are lacking. Therefore, we developed a diet-induced animal model of obesity to determine
whether obesity alters the efficacy of a standard colon cancer therapeutic, 5-Fluorouracil, in mice with
human colon cancer xenografts.
Male Rag1 mice were placed on a High Fat Western Diet (HFWD) or a Low Fat Western Diet (LFWD) for
up to 12 weeks. Body weight, biochemical parameters, and glucose and insulin tolerance were
measured. To determine the efficacy of 5-Fluorouracil on human colon cancer xenograft growth, Rag1
mice were fed a LFWD or HFWD for 8 weeks and then implanted with tissue-isolated HT-29 human colon
cancer tumors. After 3 weeks of tumor growth, the mice were randomly assigned to a drug (5Fluorouracil 40 mg/kg) or control (normal saline) treatment group. Tumor growth was monitored for 14
Significant differences in body weight, and glucose and insulin tolerance were observed in the four week
HFWD fed mice. Obesity, glucose intolerance, and insulin resistance were more pronounced in 8 and 12
week fed HFWD mice. Estimated HT-29 human colon cancer tumor growth was significantly greater in
obese HFWD fed mice compared to lean LFWD fed mice. Treatment with 5-Fluorouracil significantly
reduced HT-29 human colon cancer tumor growth in lean LFWD fed mice but was without effect in
obese HFWD fed mice.
In conclusion, our findings demonstrate that obesity impairs the efficacy of 5-Fluro Uracil in an obese
animal model of human colon cancer. Given that obesity is growing exponentially worldwide,
understanding the mechanistic links between obesity and various cancers is crucial for preventing a
significant number of patient deaths.
Mundangepfupfu, MD
Synthesis of recombinant proteins to facilitate development of a novel
Staphylococcus aureus diagnostic test.
Tichaendepi Mundangepfupfu, Debra S. Smith, Marta Pyzio, Magdalena M. Gierula, Robert J. Edwards
and Shiranee Sriskandan
Introduction: Staphylococcus aureus infection is responsible for a variety of clinical disease
presentations. While culture techniques are the gold standard for detection of S. aureus in clinical
samples the time required for results of these tests mean they have no direct effect on the acute
management of patients. The development of a cost effective rapid diagnostic test could reduce the use
of broad spectrum antibiotics for these infections and improve clinical outcomes. Previously our group
performed mass spectrometry on the culture supernatants of 14 S. aureus strains and identified eight
proteins targets with conserved C-terminal peptide sequences against which C-terminal antibodies
(CTAbs) were raised. CTAbs are antibodies targeted against a five amino acid polypeptide representing
the C-terminus of a protein of interest. They are produced by conjugating the polypeptide to a carrier
protein and then immunising an animal against this antigen. It has been shown that CTAbs are highly
sensitive and specific for a target protein. S. aureus secretes protein A which binds mammalian IgG
antibodies non-specifically. This non-specific binding can lead to false results in antibody-antigen based
diagnostic tests. To circumvent this CTAbs against S. aureus target proteins were raised in chickens,
rather than a rodent system, as chicken IgY does not interact non-specifically with protein A. The main
goal of this study was to facilitate the validation of such a diagnostic panel of CTAbs for the detection of
S. aureus from clinical samples by developing a parallel panel of recombinant proteins representing the
S. aureus diagnostic targets.
Target S. aureus genes were amplified by PCR and cloned into Escherichia coli pET19b vector.
Orientation of gene inserts and plasmid C-terminal sequence was verified by sequencing. Plasmid
constructs were transferred to E. coli expression hosts and protein expression was induced with 1M
IPTG. Recombinant proteins were extracted and western blot was used to determine the reactivity of
the IgY CTAbs with the target proteins.
Results: During this study six genes representing target proteins were successfully cloned in E. coli. The
plasmid constructs, including 5’ ends encoding C-terminal peptides, were verified by sequencing and
recombinant proteins were then expressed and purified. During this study reactivity of CTAbs against six
out of eight recombinant protein targets was confirmed by western blot.
Conclusion: These six antibodies could potentially make a rapid diagnostic panel for detecting S. aureus
directly from clinical samples. Further work is needed to validate CTAbs ability to detect S. aureus in
clinical samples.
Complete Adherence to the ACC/AHA Guidelines Equates to Improvement in
Patient Outcomes
First Author: Hafiz Muhammad Imran, MD Other Authors: Garyali S, Ayala C, Davanos E, Ansari M, Liaqat
K, Haider M, Amgad B, Abboud J, Nedelcu C.
Objective: Our objective is to evaluate the effectiveness of implementation of the new NSTEMI (Non ST
Elevation Myocardial Infarction)/UA (Unstable Angina) protocol, based on the current AHA/ACC
guidelines, in terms of improving patient outcomes and physician adherence.
Methods: We studied a total of 166 patients retrospectively. We then divided them into 86 prior to the
introduction of the NSTEMI/UA protocol(Group 1) and 80 after the implementation of the
protocol(Group 2) with pre-implementation didactic teaching involving all health care professionals
involved in the care of the patients with Acute Coronary Syndrome(ACS). We tried to evaluate the
differences in terms of race and insurance status as well. Data was collected after approval by the local
IRB. Data sets included Percentage of NSTEMI at presentation in patients who were diagnosed with ACS.
Percentage of adherence to treatment as per the protocol. Percentage of mortality –In hospital, Length
of stay in days and readmissions over the 6 month follow up. Statistical significance was assessed as per
the student t-test, with p<.05 as significant.
Results:There were 66% males in Group 1 and 69% males in Group 2. There were 69% African Americans
in Group 1 and 65% in Group 2. Hispanics were 25% and 26% in Groups 1 and 2 respectively. Whites
were 5 and 10% in Groups 1 and 2 respectively. The uninsured population was equally distributed 17%
in Group 1 and 22% in Group 2.
Patients were studied before and after the implementation of the protocol and patients studied after
the protocol implementation showed improvement in physician adherence to the protocol (59% vs.
94%, p<.001), Length Of Stay-LOS (3.53 vs. 2.75, p<.01)), In hospital mortality (5% vs. 2.5%, p<.01) and
Readmissions (35 vs. 18, p<.001). These improvements were also seen individually in all the races except
the white race, this could be explained by the fact that white race was a very low risk subset to begin
with. Also the uninsured patient population although showed significant improvement in physician
adherence to the protocol and in-hospital mortality (20% vs. 11% p<.01) the readmission rates and LOS
did not show any improvement, which could be explained by poor follow up of the uninsured
Conclusion:AHA/ACC driven protocol accompanied by a continuum of didactic learning not only
improves physician adherence and patient care it also results in significant improvements in patient
First Author: Richa Aggarwal, MBBS Ruthie Chua MD, Jennifer Poste MD, Gretel Tesado MD, Prasanta
Basak MD, Stephen Jesmajian MD
Introduction: Stress ulcers are gastric mucosal erosions that can develop in patients with a serious
illness or severe injury. However, not all hospitalized patients are at significant risk. Guidelines based on
prospective multicenter trials describe appropriate indications for stress ulcer prophylaxis (SUP). These
indications are limited to prolonged mechanical ventilation and presence of coagulopathy. Despite
guidelines that delineate the populations who derive benefit from SUP, multiple studies have estimated
that 27% to 50% of hospitalized patients empirically receive these ‘prophylactic’ medicines.
Methods: Retrospective chart review of all patients admitted to medicine service in 1/2012. We
classified patients into those (a) who were admitted with GI bleed/ gastritis/ GERD, (b) started on SUP
on admission, (c) who were discharged on acid suppressive therapy (AST). For patients already on AST
prior to admission, we identified indications for these medications based on past medical history. For
patients started on AST on the day of admission, we looked into the indications (SUP or GI bleeding). If
there was no documented indication for initiation of AST, we assumed it was for SUP. Patients started
on AST after admission and patients not admitted initially to medicine service were not included for
analysis. Data was collected in binary mode and analyzed with MS Excel.
Results: 387 charts were reviewed. 50.3% were female, and 49.7% male. Mean age was 68 years and
average duration of stay was 6 days. (a) 27/387 (7%) were admitted with GI bleed, gastritis or GERD,
requiring AST. (b) AST was ordered in 226/387 (58%) of patients admitted. Out of these patients,
175/226 (77%) had no inpatient indications for AST. (c) 149/226 (66%) of those who were started on
AST, were discharged on these medications. 71/149 (48%) patients who were newly started on AST and
discharged on it, had no documented indication from past medical history and current hospitalization
for starting and continuing AST. Thus in one month 71/387 (18%) of inpatients were inappropriately
started and discharged on AST. PPI’s and H2 blockers were used in almost similar proportions (52% vs
48%). Calculated inpatient financial burden was $11,120 per year for unindicated AST.
Conclusion: Our study highlights the common practice of non-indicated SUP use among patients
admitted to non-ICU wards. This practice not only puts an unnecessary financial burden on the health
care system, but also puts patients at increasingly appreciated risk of pneumonia, osteoporosis and
c.difficile infection.
Exome sequencing identifies a novel gene causing autosomal dominant congenital
obstructive uropathy
S Sanna-Cherchi, KE Burgess, SN Nees, N Papeta, M Choi, RV Sampogna, M Bodria, BJ Perry, A MaternaKiryluk, L Gesualdo, L Allegri, A Latos-Bielenska, F Scolari, R Ravazzolo, I Drummond, Q Al-Awqati, VD
D'agati, V Tasic, RP Lifton, GM Ghiggeri, AG Gharavi
Exome sequencing identifies a novel gene causing dominant obstructive uropathy
Simone Sanna-Cherchi1-2, Katelyn E Burgess1, Shannon N Nees1,Natalia Papeta1, Murim Choi3, Rosemary
V Sampogna1, Monica Bodria4, Brittany J Perry1, Patricia L Weng1, Vladimir J Lozanovski5, Anna MaternaKiryluk6, Nadica Ristoska-Bojkovska5, Loreto Gesualdo7, Zoran Gucev5, Landino Allegri8, Anna LatosBielenska6, Francesco Scolari9, Roberto Ravazzolo10, Krzysztof Kiryluk1, Iain Drummond11, Qais AlAwqati1, Vivette D D'agati12, Velibor Tasic5, Richard P Lifton3, Gian Marco Ghiggeri4, Ali G Gharavi1
Division Of Nephrology, Columbia University, New York; 2Department of Internal Medicine, St. Luke’sRoosevelt Hospital Center, New York; 3Department Of Genetics, Yale University, New Haven; 4Division Of
Pediatric Nephrology, G. Gaslini Institute, Genoa, Italy; 5Division Of Pediatric Nephrology, University
Children’s Hospital, Skopje, Macedonia; 6Polish Registry Of Congenital Malformations, Poznan, Poland;
Department Of Biomedical Sciences, University Of Foggia, Italy; 8Division Of Nephrology, University Of
Parma, Italy; 9Division Of Nephrology, Hospital Of Montichiari, Italy; 10Laboratory Of Molecular Genetics,
G. Gaslini Institute, Genoa, Italy; 11Department Of Genetics, Massachusetts General Hospital, Boston;
Department Of Pathology, Columbia University, New York.
Introduction: Kidney and urinary tract malformations are the most common cause of pediatric endstage renal failure. Despite epidemiological evidence for a strong hereditary component to these traits,
the underlying genetic mutations still remain elusive in the majority of cases. We sought to identify
additional alleles responsible for familial obstructive uropathy using a combination of linkage analysis
and whole exome sequencing.
Material and methods: We ascertained one multigenerational family with obstructive uropathy and
other congenital kidney malformations segregating as an autosomal dominant trait with incomplete
penetrance. We performed genome-wide linkage analysis using the Affymentrix 10K arrays, combined to
whole exome capture followed by next-generation massive parallel sequencing using the Illumina HiSeq.
We validated results in additional 311 patients. Immunohistochemistry, co-localization studies and
morpholino knock-down in Zebrafish and siRNA studies were conducted to explore the functional role of
the novel gene.
Results: Linkage analysis identified 5 loci with maximum expected LOD score of 1.5 in in the family,
confining the disease gene to 2% of the genome. Exome sequencing identified a segregating splice-site
mutation in novel gene mapping to one of the 5 loci. This gene encodes for a protein kinase of unknown
funtion. Additional heterozygous mutations, including nonsense (W8X) and splice-site mutations were
detected in 7/311 unrelated patients (2.2%) and were absent in about 7,000 population controls. The
encoded protein localizes to cell membranes with high expression in maturing epithelia of all major
organs. Morpholino-induced knockdown in zebrafish resulted in multi-organ developmental defects
resembling loss of Fibroblast Growth Factor (FGF) signaling. The protein is expressed in the ureteric bud
and metanephric mesenchyme during nephrogenesis, colocalizing with FGF receptors. siRNA
knockdown in human embryonic kidney cells inhibited FGF-stimulated ERK-phosphorylation. These data
identify a novel gene as a major determinant of human urinary tract development, downstream of FGF
Conclusions: Combining linkage analysis to exome sequencing we identified a novel gene for autosomal
dominant obstructive uropathy and congenital kidney malformations and a novel mediator in the FGF
Deficiencies in the Experiences and Confidence of Primary Care Residents with
Regard to Airway Management
First Author: James C. Fletcher, MD Contributing Authors: Kori Brewer, PhD and Reuben Johnson, MD
Introduction: Advancements in medical technology along with the increasing complexity and acuity of
patient pathology have mandated that all physicians - especially hospitalists - develop a familiarity with
airway management. However, current residency training requirements set forth by both the American
Board of Internal Medicine and the American Board of Family Medicine do not include provisions for
resident education with regard to airway management.
Objective: We sought to quantify the experiences of residents in the generalist specialties with regard to
airway management scenarios, and to accurately gauge their level of comfort with airway management.
Methods: Residents from the Southeastern and Midwestern United States in the specialties of Internal
Medicine (IM), Family Medicine (FM) and Internal Medicine/Pediatrics (IM/Peds) were solicited via their
program directors to answer an anonymous internet-based survey regarding their education, comfort,
and experiences in airway management.
Results: 197 programs were contacted for participation, representing a potential pool of approximately
5710 residents. A total of 172 responses were collected for a pooled response rate of 3.1%. Respondent
specialty distribution was as follows: Family Medicine (39.1%), Internal Medicine (38.4%), and
Medicine/Pediatrics (21.2%). The majority of respondents (70.8%) indicated that they had <5
opportunities to complete endotracheal intubation (EI) on adult patients, with only 28.5% reporting a
greater than 50% success rate throughout all attempts. Nearly two-thirds (64.7%) of EI attempts by
primary care residents occurred in an ICU setting during a required rotation. Other EI opportunities
came during Emergency Medicine rotations (14.8%) and while acting as a member of a "Code
Blue/Rapid Response Team" (10.1%). 26.1% of respondents reported that the majority of their EI
attempts occurred in emergent situations. 30.3% of respondents indicated that they received no training
in adjunctive tools for completing intubation, and 48.1% indicated that would not be comfortable
employing said techniques. Half of respondents (49.5%) indicated that their training program did not
offer and/or did not require a formal training program in airway management. 71.1% of respondents
anticipated having 15 or fewer opportunities to complete EI by the conclusion of their residency. As a
result, only 18.7% of respondents indicated that their current level of comfort with performing
advanced airway management could be characterized as "comfortable" or "very comfortable," while
only 31.5% of respondents anticipated achieving such a comfort level by the conclusion of their
Conclusions: A significant number of trainees in the primary care/generalist specialties are not
comfortable with airway management. While we recognize the limitations imposed by the somewhat
low response rate we achieved with this survey, the data obtained and apparent trends therein indicate
an emerging gap between "training guidelines" and "real world expectations," as airway management is
considered a core competency of hospitalists and is often performed by such physicians.
Extra-pulmonary Tuberculosis: A Decade of Ex perience at a Community Teaching
Hospital System in North Carolina
First Author: Megha Sawhney, MBBS Ankit Garg, MD Timothy Lane, MD
• Although the overall incidence of Mycobacterium tuberculosis is declining at the national level but
extra-pulmonary tuberculosis (EPTB ) is still found in a significant proportion of patients. EPTB is
commensurately declining but still accounts for 20% of all tuberculosis cases and at somewhat higher
proportion in immigrant populations.
• It is important to recognize the various presentations of EPTB because it is less familiar to clinicians,
more difficult to diagnose and effective therapy is frequently delayed.
• We reviewed a decade of experience with EPTB in a multi-hospital system in North Carolina in order to
alert the clinicians to the variety of presentations and appropriate diagnostic strategies.
• Retrospective chart review of patients admitted to Cone Health System from 2000 to 2010 with a
diagnosis of EPTB.
• Proven Case: Culture or PCR positive for M. TB from extra pulmonary anatomic source
• Probable pleural TB Cases: Any of the following.
1)M. TB Isolation or PCR positive for M.TB from sputum accompanied by a typical inflammatory pleural
fluid compatible with TB infection.
2)pleural fluid adenosine deaminase > 20 units/liter.
3)Pleural tissue histopathology showing granuloma or caseous necrosis.
• Possible Case: Typical presentation at extra pulmonary site and pulmonary findings compatible with
inactive TB & temporal response to anti-TB meds.
• We identified 32 cases.
• 15/32(47% ) of EPTB cases occurred among foreign born individuals which reflects current
epidemiology of pulmonary TB and EPTB reported in the U.S. Among the cases in the US residents ,
(14/17) 82% occurred in those of African- American descent while 3/17(17.6%) in Caucasians. Biological/
Genetic explanations for this finding is not understood.
• EPTB case were evenly distributed by gender and age in our cohort while other publications of EPTB
alone show a predominance of females but no biological explanation is yet available.
• 5 cases of spinal TB (Pott disease) occurred during this period and usually presented as diagnostic
dilemmas with an associated delay in diagnosis and therapy of 4.5 months from the onset of symptoms.
• 24 of the cases of EPTB had HIV testing reported and all were negative . HIV is not a common risk
factor in our patient population.
• Among the various anatomic sites of EPTB, pleural TB was the most common 7/32 (22%)followed by
TB adenitis 5/32(16%), similar to other reports in the literature.
Conclusion Although the overall incidence of Mycobacterium tuberculosis is declining at the national
level, extra-pulmonary tuberculosis is still found in a significant proportion of patients. It is clinically
important to recognize the various presentations of EPTB as seen in our study population so diagnosis
and effective therapy can be instituted in an appropriate and timely manner. v
Treatment of Left Ventricular Apical Ballooning Syndrome
First Author: Jason R Foreman, DO
Introduction: Left ventricular apical ballooning syndrome (LVABS) or Tako-tsubo cardiomyopathy, is a
syndrome of abnormal contraction of the left ventricular apex with nonobstructive coronary artery
disease. LVABS mimics acute coronary syndrome (ACS) with electrocardiographic changes, elevation of
cardiac markers, and chest pain. Emotionally triggering events occur in 44% and physical stressors in
36.2% of patients prior to the syndrome. There is no evidence supporting treatment of patients with
LVABS. To our knowledge, no studies look at the number of patients treated with anti-depressants,
anxiolytics, or receive mental health consultation. We looked to see how this patient population was
treated and their outcomes.
Methods: A retrospective chart review of patients presenting to our institution with ACS who
underwent coronary angiography from January 1, 2000 to December 31, 2010 was performed. We
identified patients with 50% or less stenosis of the coronary arteries with ejection fractions less than
60%. Coronary angiograms and ventriculograms were reviewed by a board-certified interventional
cardiologist to determine if the patients met Mayo Clinic criteria for LVABS. Charts were reviewed for
data including: age, sex, emotional or physical stressor prior to event, electrocardiography changes,
cardiac marker elevation, ejection fraction, presenting symptoms, mortality, previous diagnosis of
depression or anxiety, prescribed anti-depressants or anxiolytics on discharge, prescribed beta blocker
or ACE inhibitor on discharge, and consultation by a mental health team. Descriptive statistics were
used for the study variables listed. A total of 921 patients were screened for inclusion into the study.
Results: A total of eight patients from our institution made the inclusion criteria. The average age was
67.5 years and 87.5% were female. Twenty-five percent had an emotional stressor and 50% had a
physical stressor prior to the event. Chest pain occurred in 87.5%, ECG changes in 87.5%, and every
patient had elevated cardiac enzymes. Beta blockers were prescribed to 75% and ACE inhibitors for 25%
at discharge. No subject was prescribed a new antidepressant or anxiolytic regimen at discharge. No
patients received a mental health or psychiatry assessment while hospitalized.
Conclusions: No guidelines for the treatment of LVABS exist and the mainstay of therapy is beta
blockers and ACE inhibitors. In our patients, 75% were discharged on beta blocker therapy but only 25%
were discharged on both beta blocker and ACE inhibitor. The main goal of this study was to examine the
use of antidepressants, anxiolytics, and mental health consultations in patients with LVABS. No patient
received an antidepressant, anxiolytic, or an evaluation by a mental health team despite 25% of patients
having an emotional stressor. More studies are needed to guide the treatment in this population as
knowledge of this disease grows.
Radiation exposure from diagnostic procedures in allogeneic stem cell
transplantation - how much is acceptable?
First Author: Farhad Fakhrejahani, MD Minoo Battiwalla, MD(2) John Barrett, MD (2) (2)Hematology
Branch, National Heart Lung and Blood Institute, NIH, Bethesda, MD
Introduction: Frequent diagnostic radiology procedures in allogeneic stem cell transplantation (SCT)
recipients raise concern about the potential harm from incidental radiation. Our Objective is to
determine the cumulative effective dose from diagnostic studies in allogeneic stem cell transplantation
and its impact on clinical outcome.
Methods: Sixty four patients with hematologic malignancies undergoing radiation-based myeloablative
conditioning followed by 6/6 HLA matched sibling allogeneic stem cell transplantation. The median
follow up was three years. Our study is a Retrospective cohort study in a Single tertiary care institution.
And our main outcome measure is descriptive statistics of the cumulative effective dose in mSV from
diagnostic studies and its impact on overall survival and nonrelapse mortality.
RESULTS: The median cumulative radiation exposure from diagnostic radiologic procedures was 91.6
mSv (range 1.2-300.1), representing about less than 2.5% of a standard 1200cGy total body irradiation
(TBI) dose used in conditioning. Sixty-five percent of the cumulative radiation exposure was delivered
between day +1 and day 100 and CT scans contributed 85%. In multivariate analysis, diagnostic
procedures did not significantly impact clinical outcomes.
CONCLUSIONS: While diagnostic procedures did not impact clinical outcomes in this patient population,
the findings are important since they indicate that patients who are acutely ill for prolonged periods can
receive clinically significant radiation doses during their hospital care. Our results should prompt greater
awareness of the significant amount of radiation exposure incurred by diagnostic procedures.
Key words: HSCT, radiation, CT, outcome
Exposure to Fluconazole Leads to Resistant Candida Species
First Author: Lilian Babvani, MD, Stephen Blatt, MD Jenni Steinbrunner, BS Yury Gonzales, MD
Introduction: Candida species account for 70-80% of fungal bloodstream infections. More alarmingly, C.
glabrata possesses greater capacity to be resistant to the widely used antifungal agent, fluconazole. This
study was designed to evaluate risk factors associated with C. glabrata fungemia in relation to C.
albicans fungemia. In addition, initial treatment in relation to patient outcomes was assessed as a
secondary aim of the study.
Methods: A retrospective, multi-site study including patients over a 10 year period was conducted.
Patients admitted between January 2001 and December 2010 with at least one positive blood culture
for C. glabrata or C. albicans were included. Patients were excluded if the blood culture was ordered
within 48 hours of admission or if the blood culture was positive for both C. glabrata and C. albicans.
Patients with C. glabrata were compared to patients with C. albicans to determine potential risk factors.
Additionally, initial treatment with capsofungin was compared to initial treatment with fluconazole to
determine associated patient outcomes.
Results: There were a total of 153 patients (64 males and 89 females) who met study criteria and were
included in the study. Sixty-three patients (41%) had a positive blood culture for C. glabrata and 90
patients (59%) had a positive blood culture for C. albicans. Univariate analysis revealed that hospital
unit, other localized infection, previous antifungal use, and number of days on an antifungal were
significantly associated with C. glabrata fungemia. After multivariate analysis, the number of days on an
antifungal remained a significant predictor of C. glabrata (OR = 1.2, 95% CI = 1.0 – 1.4). Initial treatment
was not associated with patient outcomes.
Conclusion: More extensive exposure to antifungal therapy, specifically fluconazole, leads to a higher
incidence of C. glabrata fungemia. The reduction of inappropriate antifungal use is necessary to
decrease future fungal infections.
Temporal Relationships of Angina Symptoms in Obstructive Sleep Apnea and
Acute Coronary Syndrome
First Author: Neeladri Misra, MD
Introduction: Obstructive sleep apnea (OSA) affects 4 % of the population in the United States.
Burgeoning data have amassed demonstrating relationships between OSA and cardiovascular disease,
however, little data has addressed the temporal relationships of cardiac symptoms in OSA. We postulate
that angina symptoms are more likely to occur during sleep in OSA compared to matched controls in
those with acute coronary syndrome (ACS).
Methods: Patients admitted to our hospital with ACS between 2008 -2011 who underwent a cardiac
catheterization were considered in this retrospective study. We identified ACS patients with OSA
documented on polysomnography performed at our sleep lab. The timing of onset of anginal or anginal
equivalent symptons were collected from EMS data, ER notes, History and Physicals and Consultation
notes by the Cardiologist. When symptons of ACS occurred during nighttime sleep they were
considered positive.
A matched control group included ACS patients from the same time span who were low risk or had
negative polysomnography. The groups were matched for age, sex, body mass index (BMI), and
coronary artery disease risk factors such as hypertension, dyslipidemia, smoking and diabetes mellitus.
Results: A total of 90 patients (45 with OSA and 45 without OSA) comprised the analytic sample. In the
OSA group, 18 out of 45 patients developed symptoms of ACS during sleep (10PM-6AM) as compared to
the control group where only 6 out of 45 had onset of symptoms during sleep. When further subclassified into the type of ACS, the onset of symptoms during sleep in OSA vs. control group were 43.7%
vs. 12.5% in unstable angina (UA); 50% vs. 14.3% in NSTEMI; 80% vs. 40% in STEMI; and 22.2 % vs. 5.8%
in stable angina (SA).
The odds ratio of developing ACS during sleep in OSA group compared to control group was 4.33, (with p
value of 0.006, 95% confidence interval). Amongst the individual subclasses of ACS , the odds ratio were
5.4 in UA group, 5 in NSTEMI , 4 in STEMI and 2.28 in SA.
Conclusions: Based on the above results we conclude that in patients with OSA, the likelihood of
developing ACS during sleep was approximately 4 times higher compared to a similar group of patients
without OSA. These results support additional factors like hypoxia and sympathetic stimulation inducing
additional stress on the myocardium thus affecting perfusion and demand, potentially increasing risk of
acute coronary events during sleep in patients with OSA.
Anatomy of an AMA: Discharge Against Medical Advice Documentation Analysis in
a Hospital Medicine Service
Dr. Jason Edwards (associate), Dr. Dean Bricker (faculty mentor), Dr. Ronald Markert
Introduction: Discharges against medical advice (AMA) are associated with increased morbidity,
readmission rates, and 30-day mortality. Risk factors that lead to AMA have been researched, but
analysis of documentation and interventions attempted at time of discharge have not been assessed.
Methods: A chart review was performed on all AMA discharges in patients age >18 admitted to the
medical service at a community hospital occurring from January 1, 2009 to December 31, 2010
(N=291). Data analyzed included prior AMA, length of stay (LOS), presence of specific AMA note, and
time to next ED revisit and readmission. Documentation was analyzed for notation of decision making
capacity, health literacy, follow-up plan, and discharge medications given within 24 hours of discharge.
Prior AMA, follow-up plan, and discharge medications were compared to length to next encounter using
the Mann-Whitney test. Prior AMA was compared to documented follow-up plan and discharge
medications given using a chi square test. Discharge medications and follow up plan were compared to
ED revisit <31 days and readmission <31 days using a chi square test.
Results: The sample was 57.7% male (n=168) 42.3% female (n=123) with a mean age of 45.3 (SD 15.9)
years. A total of 49 (16.8% CI 13.0-21.6) had documentation of a prior AMA. Mean LOS was 2.46 (SD
2.8) days. Specific AMA notes were present in 276 (94.8% CI 91.7-96.9) with a physician author in 163
(56%). Decision making capacity and health literacy were documented in 108 (37.1% CI 31.8-42.8) and
75 (25.8% CI 21.1-31.1) respectively. Follow-up plans and medications given at discharge were
documented in 91 (31.3% CI 26.2-36.8) and 71 (24.5% CI 19.9-29.7 ) respectively. There was no
significant relationship between ED revisit <31 days or readmission <31 days and documented follow-up
plan (p=0.31 and 0.87 respectively) or medications given (p=0.12 and 0.18). Prior AMA was not
associated with documented follow-up plan (p=0.072) or discharge medications given (p=0.69).
Conclusions: Physician documentation is often lacking in cases of AMA and when present it is often
lacking in key areas. No relationships were found between interventions at time of discharge and
measures of follow up encounters. However, we do not have access to encounters not in our EMR
which could affect the outcomes. Additional areas of study include analysis of interventions for patients
threatening AMA and evaluation of outcomes of those that threaten to go AMA but are persuaded to
Uric Acid directly promotes human T-cell activation
First Author: Matlock Jeffries , MD Amr H. Sawalha, MD Ryan Webb, MS
Background: Abnormally high serum uric acid levels have been associated with several disease
conditions including gout and kidney stone disease. More recently, it was shown that uric acid crystals
stimulate dendritic cell maturation, activate the NALP3 in?ammasome, and enhance antigen-speci?c
immune responses. We hypothesize that uric acid can also stimulate T cells directly and in the absence
of antigen presentation.
Methods: Puri?ed primary human T cells were incubated with and without uric acid at concentrations of
50, 100, 150, and 200 ug/mL. The expression of T-cell activation markers CD25 and CD70 was assessed
by ?ow cytometry. In other experiments, Jurkat T cells were used and the expression of the
costimulatory molecule CD70 was determined at the mRNA level.
Results: Uric acid directly activates primary human T cells in the absence of antigen presentation.
Furthermore, primary human T cells and Jurkat T cells treated with uric acid overexpress the
costimulatory molecule CD70, which plays an important role in T cell-B cell interaction and antibody
Conclusions: The ?nding that uric acid directly promotes T-cell activation in an antigen-independent
system is novel and might play a mechanistic role in the in?ammatory response observed in gouty
arthritis and other immune-mediated disease.
Chapter Winning Abstract
J. Morton MD, J.L. Holter MD, M.K. Gumerlock MD, G. Chacko MD, K. Kedzierska MD. M.L. Smith MD, T.
Chang MD, K.M. Fung MD,PHD
Introduction: Current imaging techniques for metastatic brain lesions such as FDG-PET are limited in
specificity due to their mechanism of action which relies on glucose metabolism and thus may allow for
false positives caused by inflammation, infection, post-radiation changes, and high background uptake
in normal brain tissue. Imaging modalities to precisely define both metabolic and anatomic extent of
disease would be helpful to design more effective treatment. 18- fluorodeoxythymidine (18FLT) is a
promising new PET tracer that may allow for more accurate differentiation between tumor and
treatment effects as its mechanism of action relies on its being taken up into actively dividing cells in S
phase of DNA synthesis. Thus 18FLT may be more specific in that it does not have uptake into
inflammatory tissue or other hypermetabolic tissue which lack a high proliferative index. Purpose: The
purpose of the study is to compare the gold standard MRI imaging with FLT PET imaging in metastatic
brain lesions. Methods: Patients identified with MRI lesions requiring surgical intervention were
consented to an IRB- approved 18FLT imaging study. Patients were imaged 1-12 days pre-operatively
and the PET and MRI lesions correlated. 18 FLT values (SUVs) were measured on each of the lesions.
Tumor was submitted for detailed histopathologic study including Ki-67 labeling indices. Correlation
coefficients and standard regression statistics were performed comparing 18FLTPET imaging with gold
standard MRI imaging. Results: The mean MRI volume was 24.6 cm3 whereas the mean 18FLT volume
was 32.9 cm3 with a mean SUV of 6.6 and mean Ki-67 of 43.2 thus concluding that 18FLT is a sensitive
method to visualize highly proliferative brain lesions and is uniquely suitable for the detection of these
lesions secondary to its low background uptake in normal brain tissue. It is more sensitive than MRI in
delineating lesion margins in CNS tumors. This is the first evidence that 18FLT imaging can identify
metastatic tumors with high Ki-67 indices and is more sensitive in defining tumor extent.
A Comparison of Plastic and Metal Biliary Stents in Patients with Malignant Biliary
Obstruction from Pancreatic Cancer.
First Author: Birtukan B Cinnor, MD Additional Authors. Samir Bhalla, Kiran Bidari, Kumar Krishnan,
Srinadh Komanduri
Background: Malignant biliary obstruction is a common feature of pancreatic adenocarcinoma for which
biliary stents are often placed to alleviate symptoms, reduce the incidence of infection and provide
biliary drainage. Biliary stents are innately susceptible to eventual occlusion, which is manifested by
rising liver function tests, jaundice or cholangitis, often resulting in hospitalization and the need for
repeat intervention. Although self-expandable metal stents (SEMS) are more costly than plastic stents
(PS), the initial cost may be offset by the reduced need for reintervention and hospitalization. We aimed
to compare the duration of stent patency and rates of repeat intervention and hospitalization for both
SEMS and PS in patients with both resectable and unresectable pancreatic cancer.
Methods: We retrospectively reviewed electronic medical records for the last 315 patients who
underwent biliary stent placement for malignant biliary obstruction secondary to pancreatic
adenocarcinoma. 36 patients who underwent planned exchange of a PS were excluded. 91 patients
were found to have resectable cancer while 188 had unresectable cancer.
Results: Of the 91 patients with resectable cancer, 75 had placement of a PS while 16 had placement of
a SEMS. The median time from stent placement to surgery was 50 days (range 4-276 d). On average,
stents remained patent in PS group for 55.6 days (range 5-236 d) compared to 210.6 days (range 2-587
d) in the SEMS group. There were no significant differences between the PS and SEMS groups in terms
of stent patency (77.3 vs. 81.2%, respectively, p-value 0.07) or hospitalization (13.3 vs. 18.8%,
respectively, p-value 0.40). Of the 188 patients with unresectable cancer, 54 had placement of a PS
while 134 had placement of a SEMS. Between the PS and SEMS groups, the rates of stent patency were
44.4% and 70.2%, respectively (p- value < 0.001), and the rates of hospitalization were 27.8% and 17.9%,
respectively (p-value 0.15). On average, stents remained patent in the PS group for 77.3 days (range 3364 d) compared to 121.0 days (range 4-685 d) in the SEMS group (p value <0.001).
Conclusion: For patients with resectable pancreatic cancer there were no differences in the rates of
reintervention or hospitalization between the two groups, suggesting that placement of PS may be more
cost-effective than SEMS, since PS will maintain patency during the time required for most patients to
undergo surgery. For patients with unresectable pancreatic cancer, palliative SEMS are likely more
suitable than PS, despite the higher initial cost, given their greater ability to improve patient quality of
life and offset downstream costs by maintaining patency and reducing the need for reintervention.
Chapter Winning Abstract
Birtukan Cinnor, Samir Bhalla, Kiran Bidari, Kumar Krishnan, Srinadh Komanduri
A Comparison of Plastic and Metal Biliary Stents in Patients with Malignant Biliary Obstruction from
Pancreatic Cancer
Background: Malignant biliary obstruction is a common feature of pancreatic adenocarcinoma for which
biliary stents are often placed to alleviate symptoms, reduce the incidence of infection and provide
biliary drainage. Biliary stents are innately susceptible to eventual occlusion, which is manifested by
rising liver function tests, jaundice or cholangitis, often resulting in hospitalization and the need for
repeat intervention. Although self-expandable metal stents (SEMS) are more costly than plastic stents
(PS), the initial cost may be offset by the reduced need for reintervention and hospitalization. We aimed
to compare the duration of stent patency and rates of repeat intervention and hospitalization for both
SEMS and PS in patients with both resectable and unresectable pancreatic cancer.
Methods: We retrospectively reviewed electronic medical records for the last 315 patients who
underwent biliary stent placement for malignant biliary obstruction secondary to pancreatic
adenocarcinoma. 36 patients who underwent planned exchange of a PS were excluded. 91 patients
were found to have resectable cancer while 188 had unresectable cancer.
Results: Of the 91 patients with resectable cancer, 75 had placement of a PS while 16 had placement of
a SEMS. The median time from stent placement to surgery was 50 days (range 4-276 d). On average,
stents remained patent in PS group for 55.6 days (range 5-236 d) compared to 210.6 days (range 2-587
d) in the SEMS group. There were no significant differences between the PS and SEMS groups in terms
of stent patency (77.3 vs. 81.2%, respectively, p-value 0.07) or hospitalization (13.3 vs. 18.8%,
respectively, p-value 0.40). Of the 188 patients with unresectable cancer, 54 had placement of a PS
while 134 had placement of a SEMS. Between the PS and SEMS groups, the rates of stent patency were
44.4% and 70.2%, respectively (p- value < 0.001), and the rates of hospitalization were 27.8% and 17.9%,
respectively (p-value 0.15). On average, stents remained patent in the PS group for 77.3 days (range 3364 d) compared to 121.0 days (range 4-685 d) in the SEMS group (p value <0.001).
Conclusion: For patients with resectable pancreatic cancer there were no differences in the rates of
reintervention or hospitalization between the two groups, suggesting that placement of PS may be more
cost-effective than SEMS, since PS will maintain patency during the time required for most patients to
undergo surgery. For patients with unresectable pancreatic cancer, palliative SEMS are likely more
suitable than PS, despite the higher initial cost, given their greater ability to improve patient quality of
life and offset downstream costs by maintaining patency and reducing the need for reintervention.
Morning Ventilator Huddle and Time of Extubation in medical ICU
First Author: Tany Thaniyavarn, MD Arshad A. Wani, MD Glenn Eiger, MD Deidra P. Thomas, MS, RCP
Patricia Cannon, RN Sherry C. Pomerantz, Ph.D
Background: In order to improve the effectiveness of the ventilator weaning protocol and ensure the
efficacious communication among multidisciplinary team member, the Morning Ventilator Huddle has
been implemented in Albert Einstein Medical Center Philadelphia medical intensive care unit [MICU]
since February 2011. Extubation delay due to unavailability of extubation order, despite successful
weaning, is a potential problem in MICU. This is one of the first studies to examine the time between
weaning and extubation
Objectives: To assess the rate and etiology of the extubation delay, time between successful weaning
and extubation [extubation latency], successfulness of extubation, and ventilator length of stay [LOS]
before and after the implementation of the ventilator huddle.
Data collection and analysis: This study is a retrospective study conducted through a review of
electronic medical records. All patients in the MICU who received mechanical ventilation and were
extubated between February 15, 2010 to July 31, 2010 [Pre-Huddle group] and February 15, 2011 to July
31, 2011 [Post-Huddle group] are included. Chi-square and t-test were used for data analysis. Results: A
total of 260 cases [104 Pre-and 156 Post-Huddle] were analyzed. The Post-Huddle group has lower
extubation delay cases [13.38% VS 33.65%, p=0.001], unavailable extubation order cases [38.10% VS
71.43%, p=0.001], and mean extubation latency [24 VS 72 minutes, p= 0.001]. No difference in mean
ventilator LOS [Pre = 3.88 VS Post = 3.68 days, p=0.771] and extubation failure rate [Pre= 7.69% and
Post= 5.84%, p=0.539]
Conclusion: A Morning Ventilator Huddle leads to quicker and successful extubation.
First Author: Ahad Lodhi, MD Richard Pacitti, , David Showalter , C. Nathan Okechukwu, MD
Erythropoietin stimulating agents (ESAs) are expensive medications with significant impact on many
health-system budgets. Payers have curtailed ESA reimbursement and black box warnings have linked
ESA use with increased risk of stroke and cancers. Hospitals have developed strategies to optimize ESA
use, treating selected patients with appropriate dosing and monitoring responses. An ESA order set was
developed in March 2007 and approved by the Pharmacy and Therapeutics Committees of Crozer
Keystone Health System (CKHS) for use in the inpatient setting. Initially, usage of the form was
voluntary, followed by mandatory use in 2008 and made available across all CKHS Hospitals. This study
aims to compare ESA utilization and cost effectiveness before and after the ESA order set was
Methods: The mandatory order set restricted ESA use to FDA approved indications: anemia in CKD,
zidovudine treated HIV infections, cancer patients on chemotherapy and surgery patients undergoing
elective non cardiac, non vascular surgery. Target hemoglobin (Hgb) level was 12g/dL, dosing limited to
three days a week; with higher ESA doses were restricted to Nephrology and Hematology/Oncology.
Dose adjustment by Hgb levels was encouraged. Iron, folic acid, vitamin B12 and ascorbic acid use was
encouraged, by including them in the order set. This study is a retrospective data analysis. Data was
obtained from CKHS Pharmacy records. Buying, utilization and ESA administration records were
reviewed. Data is compared from time before ESA order set initiation from 2004 to March 2007 and
after the order form was available April 2007 to March 2010. Cost, units of ESA used with appropriate
dose conversion and number of treatments given were analyzed.
Results: ESA use decreased progressively 34.13%, 43.25% and 13.57% from 2006-2009, with a 58.1%
(116.5 million units) reduction comparing 3 years pre and post ESA order set initiation. Cost increased
9.28% ($199, 053) and 20.52% ($553, 921) respectively from 2004-2006. After ESA form initiation in
March 2007, cost decreased 30.88% ($887,698), 51.23% ($928,367) and 28.67% ($253,410) respectively
from 2007-2009. There was an overall cost reduction of 57.4% ($3,935,574) comparing 3 years pre and
post order set implementation. ESA treatments administered remained similar; 28,826 compared to 24,
699 after order set implementation.
Conclusion: The mandatory order set helped CKHS optimize ESA use. Most notably realizing cost savings,
without significant loss of treatments provided and minimizing the complications associated with excess
ESA use. Dosing, frequency and appropriate patient population for ESA are clearly defined by the order
set, achieving standard Hgb targets. Our ESA order form will continue to evolve according to new
recommendations and similar orders sets can help healthcare systems and hospitals across the country.
Robleza Non, MD
The Value of Clinical Prediction in Repeat Testing with Enzyme Immunoassay for
Clostridium difficile.
First Author: Lemuel Benedict Robleza Non, MD Secondary Author: Jerry Zuckerman, MD
Introduction: Enzyme immunoassay (EIA), with sensitivity of 70-80% and specificityof 94%, is the most
commonly used diagnostic tool in the diagnosis of Clostridium difficile because of its rapid turnaround
time and low cost. Repeat testing with EIA has been a practice among hospitalists to compensate for the
low sensitivity but this has been recently questioned. Clinical prediction rules on diagnosis of C. diff with
acceptable specificity and sensitivity has recently emerged and may have a role in diagnosis. This study
aimed to determine the value of repeat testing in our facility and whether the addition of clinical data
can help in clinical decision making.
Method: A retrospective chart review of 91 patients with suspected C diff-associated diarrhea (CDAD)
who had subsequent testing after an initially negative result was conducted. The primary outcome was
positive yield with repeat EIA testing within 7 days of an initial negative test. Known clinical predictors
for C diff, including recent hospitalization, WBC, albumin level,immune-suppression, PPI or H2B use,
were also identified in each patient to find out if individually or as a composite they favor repeat testing.
Result: Ninety two percent (92%) of the subjects were negative, and 8 % turned out positive within 7
days after the initial negative test. Of clinical variables examined, no individual variable or even a
composite of variables was found to strongly predict positivity after an initial negative test.
Conclusion: The positivity rate in this study with repeat EIA testing is about three times more common
than in reported literature (~1.9-2.5%), and favors repeat testing if EIA remains the only the diagnostic
test available. While clinical prediction may be useful in decision making in the initial diagnosis of CDAD,
this study found no role in using it in deciding repeat testing with EIA.
First Author: Arvind Vasudevan, MD Additional Authors: Snigdha Kurimilla,MD; Sandhya
Samavedam,MD; Maureen Kane,RN; Jeremiah Eagen,MD;Joseph Leo,DO.
Background: Transfusion practices vary worldwide given the diverse clinical situations necessitating
transfusions. Over 1.32 Million PRBC Units in the USA are transfused annually. Given the infectious and
non-infectious risks associated with transfusion as well as data not showing superior outcome with
liberal red blood cell transfusion, current guidelines support a restrictive strategy.
Purpose: Using the latest guidelines and literature, we aimed to improve appropriateness of
transfusions in the intensive care setting, lower the number of transfusions and associated costs.
Description: In a mixed Medical-Surgical Intensive care setting in a community hospital, we created a
hospital order set using the most recent literature and evidence based guidelines. Nursing staff,
physicians and allied healthcare workers were educated on latest guidelines and order set usage.
Multiple educational sessions and grand rounds for physicians and nurses helped increase awareness.
Data was collected over one year (June 2011 – May 2012) on all transfusions in the ICU.
574 Units of PRBC were transfused during the period. A 29% reduction (336 to 238 units) was observed
while comparing data from initial 6 months with data from the subsequent 6 months. This accounted to
a reduction in cost by $63210 (Cost of transfusion is $645/unit which excluded administration costs).
Moreover, mean transfusion rate in the corresponding time periods reduced from 3 to 2 units per
patient. (Mean 5 units per patient; from transfusion trials in critical care and trauma centers).
Appropriateness of transfusion before the start of this project was 26% and the rate improved in each
quarter - 67.6%, 90%, 77% and 77% (an average of 79%).
28.38% (65/229) patients developed AKI post transfusion. Post transfusion fluid overload incidence was
20%. All cause mortality was 16.6%(13-25% in reported studies). There was no reported data of the
incidences of AKI and fluid overload in other studies to compare with.
Conclusions: Using evidence-based protocol driven transfusion order set leads to an improved clinical
practice and reduces associated healthcare costs.
Non-receptor tyrosine kinase c-Src activity can predict anti-EGFR therapeutic
response in metastatic colorectal cancer patients.
First Author: Janghee Woo, MD,PhD John C. Leighton
Introduction: Cetuximab, a chimeric murine human IgG1 antibody, was the first Anti-EGFR monoclonal
antibody (MAb) to demonstrate efficacy in metastatic colorectal cancer (mCRC). However, the best
responses of cetuximab in KRAS/BRAF wild-type tumors do not last for longer than 12 to 18 months and
the tumors eventually relapse. While molecular mechanisms of resistance to anti-EGFR MAbs have been
extensively investigated, only KRAS mutations were identified as response predictive markers to confer
resistance in mCRC. Recent studies showed that non-receptor tyrosine kinase c-Src activity can play the
role of a key node, activating multiple signaling pathways. The activated pathways implicated conferring
resistance against the anti-EGFR/HER2 therapy. In order to understand underlying the mechanism of
resistance and prospectively predict outcome of cetuximab treatment, this study investigated whether
activated c-Src can confer the anti-EGFR resistance by providing bypass mechanisms to activate
downstream-oncogenic signaling pathways. Methods: Src activation was assessed by
immunohistochemistry, using a validated antibody against phosphorylated Src at Tyr416 (p-SrcY416), in
primary colorectal cancers from the patients who were subsequently treated with chemotherapy and
cetuximab. All patients received cetuximab in the first line therapy or salvage therapy combined with
chemotherapy. c-Src activity correlated with clinico-pathological features and oncogenic mutations
including KRAS, BRAF and PIK3CA. We retrospectively evaluated c-Src activity and progression free
survival (PFS) and overall survival (OS) by Kaplan–Meier analysis in total 68 patients with mCRCs.
Subgroup analysis was performed with respect to KRAS mutation. Results: phospho-Src antibody
unambiguously stained tumor cells in 23 cases (33.8%). The higher level of c-Src activity (p-Srchigh) was
not associated with KRAS, BRAF and PI3CA mutations, while it was positively associated with tumors
occurring in the proximal colon. The overall survival month of patients who received cetuximab in any
lines of therapy for mCRC was comparable between p-Srchigh tumors and p-Srclow/- tumors (median OS pSrchigh 31.73m, 95%CI:28.225-35.035 vs p-Srclow/- 31.63m, 95%CI: 27.326-36.134, Log Rank p=0.810).
However, the PFS months of patients with p-Srchigh tumors (median PFS 2.78m, 95%CI:2.201-3.359) was
significantly lower than that of patients with p-Srclow/- tumors (4.37m, 95%CI:0.976-7.764) (HR 2.033,
95%CI1.130-3.66, Cox-regression p=0.018). Tumors from 23 patients (33.8%) harbored KRAS mutation
and 45 patients carried KRAS wild-type alleles. In the mCRC patients with KRAS wild-type tumor, the
progression free survival of patients with p-Srchigh tumors (median PFS 2.83m) was significantly lower
than that of patients with p-Srclow/- tumors (5.89 months) (HR 2.342, 95%CI 1.032-5.32, Cox-regression
p=0.042), while patients with KRAS mutant tumors failed to demonstrate significant difference in the
progression free survival (p-Srchigh: 2.33 months and p-Srclow/-: 2.51 months). Discussion: Patients with
KRASWT;p-Srchigh tumors exhibited significantly less benefit of cetuximab treatment despite tumors
with KRAS wild-type. It indicates that the activation of c-Src may confer resistance to anti-EGFR therapy
in patients with mCRC. c-Src activation in mCRCs may therefore have value as a predictive marker for
cetuximab response and in stratifying patients before treatment.
Comparison of TIMI score and Troponin I in determining outcomes in
Nonagenarians post Acute Coronary events
First Author: Shailendra Singh, MD Second Author: Andrew Kohut, MD Third Author: Ronald
Chamberlain, MD
Background: Individuals living greater than 90 years old (yo) is projected to double and reach 9.6 million
by 2030. Nearly 55,000 nonagenarians suffer acute coronary events (ACE) annually. Due to the paucity
of literature, this study sought to characterize functional outcomes following ACE in individuals of
advanced age by comparing Thrombolysis in Myocardial Infarction (TIMI) score and peak serum
Troponin I (TnI) levels.
Methods: 7,687 patients (pts) over 90 yo were admitted to Saint Barnabas Medical Center, Livingston,
NJ between 2000 and 2010. Age, gender, diagnosis, TIMI score, cardiac biomarkers, and discharge status
were abstracted. Outcomes were defined by discharge disposition (refer to Table 1).
Results: 243 pts over 90 yo were admitted for ACE. The mean age among pts was 93.4 (91-103) years
old. When assessing unfavorable outcomes, a high TIMI risk score was ascertained in 22% of pts where
as a high TnI risk score was found in 87% of pts (Table 1). A TnI level is a better predictor of outcomes
versus a TIMI risk score in this nonagenarian population.
Conclusion: Pts over the age of 90 are a growing population that will utilize increasing health care
resources and outcomes following ACE in this age group are poor with a mortality of 11.9%. Our data
suggests that a peak serum TnI level is a better predictor of outcomes versus a TIMI risk score in our
nonagenarian population. Additional research is required to prevent, identify and treat the causes of
ACE and reduce the high mortality following ACE in this age group.
Table 1
Intermediate High
17 16.7%
26 27.1%
10 22.2%
112 46.1%
53 21.8%
Intermediate High
40 41.7%
39 86.7%
83 34.2%
TIMI score: Low (1-3), Intermediate (4), High (5-7)
TnI Levels: Low(0.00-0.04), Intermediate (0.05-0.12), High (>0.12)
Discharge Outcomes
Favorable - discharged to home with home health service
Intermediate - discharged to skilled nursing/rehabilitation facility
Poor - in hospital mortality and discharges to hospice care.
Tuberculin Skin Test versus Interferon-Gamma-Release Assays for initial screening
of health care professionals
First Author: Monish A Sheth, MBBS Vishal Patel, MBBS Co-Author: Mohamed Yassin, MD, PhD Mehrshid
Introduction: Annual Tuberculosis (TB) screening is mandatory in all health care professionals.
Tuberculin skin test (TST) is the standard test used to check for latent TB regardless of the bacillus
Calmette-Guerin (BCG) vaccination history. Previous studies using TST have estimated prevalence of
Latent TB to be 4% among overall US population and 19% among those that are foreign born (most with
a history of BCG vaccination). TST offers little discrimination between true latent TB and positive TST due
to BCG vaccination. The guidelines recommend Interferon-Gamma-Release Assays (IGRAs) for latent TB
screening in individuals with previous BCG vaccination.
Method: This is a descriptive analytical study to find the prevalence of false positive latent TB in our
University-based residency training program using IGRA as a confirmatory test. Data was collected
through a questionnaire filled by seventy internal medicine residents. All the residents in our program
were asked to participate.
Result:Seventy residents filled a questionnaire of which 28 (40%) were US medical graduates and 42
(60%) were international medical graduates (IMG's). 19 (27%) residents had a positive TST, all of them
were IMG's. 17(89%) of the 19 cases of positive TST had received BCG previously. 10 residents took the
initiative to get an IGRA, all of them with history of BCG vaccination; only 3 had a positive IGRA and 7
(70%) were negative IGRA test (false positive TST).
Conclusion: There is a high false positive rate of TST among foreign-born residents in our residency
program. IGRA should be the first line screening test for individuals with history of BCG vaccination.
Actual latent TB, not false positive TST, should be treated to prevent progression to clinical TB. This
study is a pilot study with highly significant results that could lead to change in practice and further
compliance with the guidelines.
Short-Term Corticosteroid Use And Hyperglycemia In Hospitalized Patients
First Author: Yu Kuang Lai, MD, Davi Sa Leitao MD, Ha Nguyen MD, Arthur Chernoff MD, Sherry
Pomerantz PhD
Introduction: Hyperglycemia is a well-known adverse effect of corticosteroids use. A retrospective study
was conducted to assess the in-hospital prevalence and associated risk factors for developing
hyperglycemia in non-diabetic patients.
Methods: A retrospective review of medical records was conducted on patients who received
corticosteroids during hospital admission in an urban tertiary-care hospital from May 2010 to January
2011. Patients with conditions associated with hyperglycemia or steroids use prior to admission were
excluded. Steroid-induced diabetes mellitus (SIDM) defined as 2 fasting glucose of = 126 mg/dl, or a
random glucose of =200 mg/dl. Glucose intolerance defined as fasting glucose = 100mg/dl but <
126mg/dl.Variables such as body mass index, age, race, co-morbidities, medications, dose and type of
steroids, route of administration and duration were compared between hyperglycemic group (glucose
intolerance and SIDM) and normoglycemic group.
Results: Sample of 250 patients were eligible for the study. One hundred and eighty four patients
(73.6%) developed hyperglycemia. Beta blocker use, duration and patient who received both
intravenous and oral corticosteroids were found to be associated with hyperglycemia ( p-value= 0.028,
0.00, 0.019 respectively ). SIDM was diagnosed in 94 patients (38%).Mean glucose reading in SIDM
group was 235mg/dl (SD 74.41mg/dl ) and 46.8% received glucose monitoring and intervention.
Conclusion: In-hospital use of corticosteroids is associated with a high occurrence of hyperglycemia. A
third of patients developed SIDM with only 46.8% receiving glucose monitoring and intervention.
Duration and route of administration of corticosteroids were found to have strong correlation with
A multi-center study of physician knowledge of patient fall risk
First Author: Anitha Somasundaram Second Author: J Christian Third Author: N Chaudhry Fourth Author:
A Thapliyal Fifth Author: W Zirker Sixth Author: A Eiser Seventh Author: M Musuku
Background: Falls are the leading cause of injury death among adults 65 or older. Physician knowledge
of fall risk factors is crucial to reducing falls. Interventions targeting fall risk factors can reduce fall rates
by 30-40%. Yet national studies show that screening conducted by physicians is often short of
acceptable standards. The objective of this study was to assess physician knowledge and behavior on
inpatient falls.
Methods: The survey was conducted at four different hospitals. Data was collected via anonymous
survey e-mailed to medical residents and attendings. The survey had 17 questions pertaining to falls
knowledge (including AGS guidelines), knowledge about their hospital fall protocols and physician
behavior when treating patients with fall risk.
Results: A total of 353 surveys were sent and176 responses (50%) were obtained and analyzed. 71%(N=
125) of the physicians were not aware of the exercise programs that reduce falls. 51% correctly
identified that higher doses of vitamin D reduce falls. 90% correctly identified the medications that
increase fall risk in patients. 41% correctly identified the local fall risk model being used at their hospital.
Only 11% of physicians always asked their elderly patients for a history of fall and 19% always checked
orthostatic hypotension in patients with a fall at the time of admission. When the physicians’
performance on knowledge was graded, 69%(N= 121) had satisfactory performance (4-6 correct answers
from 8 questions). No significant inter-hospital differences (p value 0.38) were found. On physician
knowledge in fall local protocols, again there was no significant inter-hospital difference (p value 0.93).
There was no significant difference in physician knowledge between residents and attending physicians
(p value 0.91). However, residents knew significantly more than attendings about their hospital’s fall
protocols (p value 0.0033).
Conclusion: This study highlights that though physicians have some knowledge of falls, there are definite
gaps in physicians’ knowledge and behavior when screening patients with fall risk. Targeted efforts to
improve physicians’ knowledge of falls through structured teaching during training and medical staff
training can address these issues. Previous studies have shown that dissemination of evidence about fall
prevention, coupled with interventions in clinical practice, may reduce fall related injuries in elderly
IV INFILTRATION - Reducing Hospital Incidence, Increasing Patient Safety
First Author: Ayodeji O Adegunsoye, M.D. Adegunsoye, Ayodeji M.D. Sharmeen, Sabina M.D., Mackay,
Emily D.O., Baba, Riaz M.D., KC, Ramesh M.D., Bhattrai, Yagna M.D., Eiser, Arnold M.D., FACP
Introduction: About 150 million infusions are administered yearly in the US and 20% of hospitalized
patients develop IV infiltrations with potential life or limb threatening consequences. Our QI project
targets simultaneous reduction in occurrence and complications via novel approaches.
Methods: We administered de-identified single page questionnaires to 100 nurses to determine
awareness of current guidelines for IV placement and perception of infiltration occurrence. We further
implemented a multi-center retrospective chart review of 190 patients with major IV complications over
the past year to determine associated key factors.
Results: Our survey was notable for 100% return rate and showed acceptable knowledge of standard
practices but significant discordance between perception, actual incidence and modalities for managing
infiltrated IVs. 97% of our respondents were unaware of guidelines for IV placement and 92% unaware
of protocols for managing infiltrations (95%CI=86.7%-97.3%). Most complications (95.3%) occur in
radiology suites, in-patient medical floors and the ED (95% CI=92.2%-98.3%) and are recorded within
72hrs (83.7%) of admission (95%CI=78.4%-88.9%). About 1 in 4 nurses (22%) never inform physicians
about major IV complications (95%CI=13.9%-30.1%) delaying early and appropriate
Conclusion: Utilizing input from multiple interdisciplinary collaboration sessions, we designed a hybrid
single-page poster for all units outlining standardized guidelines for peripheral IV placement, infiltration
prevention and a hospital protocol for therapeutic management of infiltrated IVs including infusionspecific antidotes. We also developed biannual online competency modules for completion by all nurses
and physicians prior to participation in an annual IV skills workshop and will track occurrence of
infiltration and complications post-intervention.
Hidden Barriers & Possible Solutions: A Quality Improvement Project to Improve
the Length of Hospital Stay in Patients with Diabetic Foot Infections
Hyo Y Lee, DO, Leena Jalota MD, Naba Mainali MD, Anthony Donato MD.
Statement of Problem: Diabetic foot infections account for the largest number of diabetes-related
hospital admissions, and the hospitalizations account for 71-88% of all diabetes related expenditure.
The length of stay is the major contributor to costs. Objectives of Intervention: To decrease the
diabetes related expenditure, our quality improvement project aim was to decrease the length of
hospital stay in patients with diabetic foot infections by 2 days over a 6-month period. Description of
Program/ Intervention: Based on chart review of patients admitted to the hospital with diabetic foot
infections, 6 critical steps were identified as potential contributors of prolonged hospital stay: time to
surgical debridement, imaging wait times, vascular studies, pathology reports, PICC line placement,
antibiotic arrangement and wound management. The measures selected to quantify the effects of our
interventions included a outcome measure (median length of hospital stay), two process measures (time
to foot debridement, and time from foot debridement to pathology report) and a balancing measure
(30-day readmission rate). Measures of success: Our interventions were (1) a meeting with all the
involved stakeholders to expedite steps to decrease the length of hospital stay, (2) launching a
standardized, evidence-based diabetic foot order set to coordinate management, and (3) meeting with
podiatry to discuss delayed consults and provide report cards. Findings to Date: After the
implementations of interventions, the length of hospital stay in patients with diabetic foot improved,
which correlated with improvements in both process measures for the two months since
implementation of our third cycle. Key Lessons Learned: More study is needed to see if gains can be
sustained, and further identification of outlier cases is necessary to craft future interventions.
Nwakile, MBBS
Chapter Winning Abstract
Chinualumogu Nwakile MD, Bhaskar Purushottam MD, Jeong Yun MD, MPH, Christian F. Witzke, D. Lynn
Morris MD, Vincent M. Figueredo MD
Chinualumogu Nwakile MD, Bhaskar Purushottam MD, Jeong Yun MD, MPH, Christian F. Witzke, D. Lynn
Morris MD, Vincent M. Figueredo MD
Background: The significance of ST-T segment changes in ST elevation myocardial infarction (STEMI)
patients has been well described. However, there is limited data on the significance of QRS duration in
STEMI. Our objectives were to determine the impact of QRS duration on the 30-day mortality and
ventricular arrhythmias in patients with STEMI.
Methods: In this retrospective study, 553 patients with STEMI from 2006 to 2011 at Einstein Medical
Center, Philadelphia were studied. Patients with a baseline QRS duration >100 ms, paced rhythms and
bundle branch blocks on admission were excluded. The 30-day mortality and the occurrence of
ventricular arrhythmias were compared between patients with a QRS duration >100ms and those with
Results: The final cohort consisted of 474 patients with mean age 61+14 yrs and 42% female. Patients
with a QRS duration >100ms had an increased 30-day mortality (HR=2.03, 95%CI 1.2-3.4; p<0.01) and
occurrence of ventricular arrhythmias (OR=2.17, 95%CI 1.3-3.5; p<0.01) compared with patients with
QRS duration <100ms (TIMI score variables, chronic kidney disease, hypotension and tachycardia were
Conclusions: QRS duration >100ms is an independent predictor of 30 day mortality and inpatient
ventricular arrhythmias after STEMI. QRS duration should be strongly considered in further STEMI risk
stratification and aggressive arrhythmia management.
The Epworth Sleepiness Scale and its correlation with the Severity of Obstructive
Sleep Apnea in the PR population
Montalvo-Galiano, Clary, M.D Román-Vélez, Jesús M., M.D., ABIM, Diplomate of The American Board of
Pulmonary Medicine, Diplomate of the American Board of Sleep Medicine
Obstructive Sleep Apnea (OSA) is a common sleep-related breathing disorder that
involves a decrease or complete halt in airflow despite an ongoing effort to breath. This
condition is diagnosed and stratify utilizing the patient’s history, overnight Polysomnography
Test and the Apnea Hipoapnea Index (AHI). Despite this, Pulmonary Medicine counts with
several methods that can complement the diagnosis. One of these methods, known as The
Epworth Sleepiness Scale, has become the most frequent questionnaire use worldwide to
assess a person’s average level of daytime sleepiness; factor that has been related with the
severity of Obstructive Sleep Apnea.
Previous studies worldwide had questioned the utility and validity of the Epworth
Sleepiness Scale correlating severity of daytime sleepiness and OSA. This, because the scale has
been translated to multiple languages and also due to the fact that this is a subjective
questionnaire. To our knowledge, there is no published study on this subject in the Puerto Rico
population. The purpose of this study is to determine the correlation between the severity of
the Epworth Sleepiness Scale and Obstructive Sleep Apnea determined by Polysomnography in
the Puertorican population.
This is a retrospective observational randomized trial performed in the Laboratorio del
Sueño (Labsu) in Mayagüez, Puerto Rico; between August and September of 2011. The study
consist of a sample of 257 puertorican adult patients (18 to 79 years old) who underwent
overnight Polysomnography Test. Population consisted of 36% females and 64% males.
Evaluation was complemented with the Epworth Sleepiness Scale.
All patients who underwent Polysomnography Test were included in the study. Patients
that were not diagnosed with Obstructive Sleep Apnea (2), or with no available Epworth
Sleepiness Scale questionnaire (3) were excluded from the study. After statistical analysis the
Spearman’s Correlation Coefficient Score between the AHI and the Epworth Sleepiness Scale is
of 0.32 (p<0.0001) for the general population. With a significant association in the female
population (p: 0.0124) and in the male population (p <0.001).
This study had found a very significant statistical correlation between the severity of
OSA and daytime sleepiness in the female and male puertorican population;
being stronger in the latest one. This could be related to the way in which males and
females expressed their lack of sleep and tiredness. Despite controversy, this study
demonstrate the utility of the Epworth Sleepiness Scale as a tool for the evaluation of patients
with Obstructive Sleep Apnea in the puertorican population.
Chapter Winning Abstract Effect of Vitamin D in Critically Ill Patients
Michael Agustin MD, Natascha Esber MD, Vera De Palo MD, Mary Roberts MS
Introduction : Vitamin D modulates a variety of processes including host defense, inflammation,
immunity and repair. Vitamin D deficiency is thought to be prevalent in critically ill patients admitted to
the Intensive Care Unit (ICU). Lack of sunlight and nutritional impairment are implicated causes. We
sought to examine Vitamin D deficiency in ICU patients relating to their outcome.
Methods : We collected the Vitamin D levels of ICU patients at the MHRI from July 1 – Dec 31, 2010,
whose Vitamin D was checked during their ICU stay. Demographics, co-morbidities, clinical, laboratory
and outcome variables were recorded. Simplified Acute Physiologic Score II (SAPS II) was computed.
Patients were categorized into low (<30 ng/ml ) and optimal level groups (>30 ng/ml) based on their
Vitamin D level. Patients categorized into the low level group were further subdivided into undetectable
(=10 ng/ ml ), deficient (11- 20 ng/ml) and insufficient (21-29 ng/ml). The project was approved by the
Institutional Review Board and statistical analysis was performed.
Results: Of 354 patients admitted to the ICU between July 1 to Dec 31, 2010, only 41 (11%) had Vitamin
D levels checked. Of those, 35 (85%) had low levels of Vitamin D. Twenty four percent (10/41) were in
the undetectable group, 29% (12/41) in the deficient group, 32% (13/41) were classified as insufficient.
Only 15% (6/41) had normal Vitamin D level. Sixty six percent (23/35) of patients were over 65 years of
age in the low level group. The median ICU length of stay was 8 days and Hospital length of stay was 13
days on low level group.
Using generalized linear mixed model approach, older age and Vitamin D deficiency significantly
associated with ICU length of stay (p < 0.0001) and hospital length of stay (p < 0.0001).
Conclusion: The value of Vitamin D in the human body goes beyond the calcium – bone homeostasis.
The severity of Vitamin D deficiency in elderly patients seems to be predictive of longer ICU and hospital
lengths of stay. Further study is needed which may lead to the recommendation of supplementation in
elderly patient to better improve outcome.
Chapter Winning Abstract
Maneesh Penkar, MD James Lennon, DO
Abstract Title:
PURPOSE: To Determine Rate of GI Bleeds post PCI at GHS and to identify possible risk factors that
predispose a patient to a GI bleed post PCI.
INTRODUCTION: In the United States there are over 1 million PCI performed per year. The use of dual
antiplatelet regimens increases the risk for bleeding in patients, with gastrointestinal bleeding being the
second most common site of bleeding post PCI. This results in an increased mortality as well as
increased cost to the health care system.
Methods: This was a retrospective analysis of 15,600 patients who underwent a PCI at GMH over a
period of 7 years. We defined a GI bleed as a drop in hematocrit of greater than or less than 10%, a drop
in hemoglobin of greater than or less than 3 gm/dl, or a patient who required a transfusion of Packed
Red Blood Cells post PCI. Bivariate analyses of PCI patients with and without post-PCI GI bleeds were
compared using Student’s t-test for continuously-distributed data and the Chi-square test for categorical
data. Multivariate logistic regression analysis was used to assess independent predictors of a GI Bleed.
All data analyses were performed using SAS software (Statistical Analysis System, Cary, NC, Version 9.2).
Statistical significance was assessed at alpha=0.05.
Results: There was a total of 15,600 PCI in this study with a total of 91 patients with GI bleeds. The risk
factors identified for a GI bleed (p value <0.05) were a low BMI, age >70 years old, congestive heart
failure, renal failure, chronic obstructive pulmonary disease (COPD), cerebral vascular accident,
peripheral vascular disease, presentation of ST elevation myocardial infarction (STEMI), and prolonged
length of procedure. A logistical regression model was used to predict outcomes from the patient
populations found to be most at risk for a GI bleed. Characteristics which had poor outcomes using a
95% confidence interval were age >70 (odds ratio 2.67), lower BMI (odds ratio 0.96), history of COPD
(odds ratio 2.06), history of renal failure (odds ratio 6.36) and those who presented with an ST elevated
myocardial infarction(STEMI) (odds ratio 4.86).
Conclusion: This study revealed that older age, renal failure, COPD, a low BMI and presentation with a
STEMI are all important independent risk factors for a GI bleed post PCI. This study demonstrates that GI
bleeding post PCI is associated with increased mortality and increased length of stay.
A Novel Approach with A Novel Product: Aerosolizing Phytobacteria for
First Author: Matthew D Stone, MD Additional Authors: David Bemis, PhD Mark Rasnake, MD FACP
Background: Hospital equipment can harbor pathogenic bacteria and play a role in transmission of
nosocomial pathogens. Disinfection is often suboptimal, and many disinfectants are corrosive and can
degrade material such as sensitive electronic devices. We conducted a study of a novel disinfectant
composed of nonpathogenic phytobacteria. This product is nonirritant and noncorrosive and has broad
antiviral, antifungal, and antibacterial activity.
Methods: A study was performed with metal discs inoculated with a known concentration of
pathogenic bacteria. IRB approval was obtained and an outside lab was used to inoculate metal discs
with methicillin-resistant Staphlycoccus aureus (MRSA), vancomycin-resistant enterococci (VRE),
Acinetobacter baumanii, and Klebsiella pneumoniae. Discs with organism burdems of 103, 104, 105, and
106 colony forming units were prepared. Discs were then placed in a simulated patient room with
groups of discs placed in covered and open areas. A prototype machine was then used to aerosolize a
solution of phytobacteria based disinfectant. The room was fogged for a variable amount of time and
then allowed to settle for 15 minutes. Discs were collected and cultured in broth to evaluate for any
growth after exposure to the disinfectant. A control set of discs were not exposed to disinfectants.
Results: Uncovered bacteria with direct exposure showed no growth of any pathogens at inoculations
of 104 or less. Higher organism burdens of MRSA and VRE were more resistant to inactivation.
Uncovered disc with indirect exposure had no growth up to10x-3 colony units for MRSA, 10x-4 colony
units for VRE, 10x-5 colony units for K. pneumoniae, and all concentrations for A. baumanii. The covered
bacteria had post-exposure growth at all concentrations except in the K. pneumoniae and A. baumanii
groups which both had no growth up to 10x-5 colony units. All control discs had growth at all
Conclusion: This study demonstrates the effectiveness of a phytobacteria based disinfectant in
decontaminating hospital equipment. Initial results indicate the importance direct contact with the
disinfectant. Given the non-irritant nature of phytobacteria, an aerosolized solution was tested to see if
it could be a viable alternative to labor intensive room cleaning or as an adjunctive measure to reduce
organism burdens in previously cleaned rooms. The phytobacteria appear to be well suited for this task,
however, more studies are needed to assure appropriate time and exposure levels. Also high organism
burdens continued to have growth further emphasizing the importance of thorough cleaning of soiled
areas. Potential advantages of the novel product include its non-corrosive and non-irritant properties,
making it safer for personnel and equipment. Phytobacteria based disinfectants are a promising
addition to currently available disinfectants.
An Assessment of Coliform Bacteria in Water Sources near Appalachian Trail
Shelters within The Great Smoky Mountains National Park
First Author: Brian C Reed, MD Mark Rasnake, MD
Introduction: Hikers and campers are exposed to dangers while in the wilderness. One of these is the
possibility of contracting an illness, most commonly infectious diarrhea due to coliform bacteria, giardia
or cryptosporidium. It has long been held that drinking water obtained from wilderness sources should
be treated by some mechanism prior to drinking. Compliance with this practice among hikers is variable
as many assume “pristine” wilderness water sources are safe. This project focuses on coliform bacteria
in water samples taken near popular Appalachian Trail shelters during two seasons. We present the
coliform test results from an ongoing study of bacterial flora in high elevation springs.
Methods: Water was collected from designated water access points near 10 high elevation trail shelters
within the Great Smoky Mountains National Park (GSMNP) during summer and fall months. Samples for
coliform culture were collected in sterile bottles and transported unfrozen to the laboratory. These
samples were inoculated on a commercial coliform detection kit (Coliplate™, Blue Water Biosciences)
for quantitative determination of total coliform counts and Escherichia coli counts.
Results: Water samples were taken during summer and fall seasons. During summer, 7 out of 10
samples were positive for coliform bacteria and 6 for E. coli. The most probable number (MPN) of colony
forming units (CFU) was determined per manufacturer’s directions. The MPN of CFU for coliform
bacteria ranged from 0 to 489 CFU/100mL, with the MPN for E. coli varying from 0 to 123 CFU/100mL. A
total of three sites were negative for coliform bacteria. These data differed from the fall collection,
revealing 4 out of 7 samples positive for coliform bacteria and 1 for E. coli. The MPN of CFU for coliform
bacteria varied from 0 to 119 CFU/100mL and 0 to 5 to CFU/100mL for E. coli.
Conclusion: EPA drinking water standards require 0 CFU/ 100mL to be considered safe. After a
preliminary analysis of 10 water sources along Appalachian Trail, the majority of water access points
require treatment during the summer season. Coliform burden was not as worrisome through the fall
months, though was still a concern for some sites. Appearance of the water supply is not a reliable
indicator of water quality, as water at all sites sampled as part of this study appeared clear to the naked
eye. This data will illuminate infectious disease risks for wilderness travelers and promote safe drinking
water practices amongst backcountry travelers.
Risk factors, Complications, and Mortality among Infective Endocarditis Patients
at a Tertiary Care Medical Center
First Author: Swara Afiniwala, MD, Rupert Stanborough MS4, Mark S. Rasnake M.D., FACP
Introduction: Infective endocarditis (IE) has become more prevalence in conjugation with an increase in
narcotic abuse, particularly Intravenous drug abuse (IVDA) in the last decade. Our recent clinical
experience suggested that injection drug use accounted for the majority of endocarditis treated at our
institution, and that many presented with left sided, rather than the classic right sided disease.
Additionally, troponin elevations have been shown in previous studies to predict worse outcomes in IE,
consistent with our anecdotal findings. We sought to determine the prevalence of IE at our institution as
well as to determine what factors predicted poor outcomes.
Methods: We conducted a retrospective review of patients diagnosed with infective endocarditis over a
two year period. Variables examined in this study included history of IVDA, valve involved, need for
surgical intervention with repair or replacement, clinical complications such as pulmonary or cerebral
emboli, and type of microorganism isolated from blood cultures. Variables predicting complications of
IE as well as mortality were analyzed with Mann-Whitney U tests and categorical variables were
compared using either chi square or Fisher exact tests as appropriate.
Results: Our endocarditis population was predominantly young (mean age 48) and male (56%). Of the
80 patients reviewed, 46 (57.5%) had a definite history of IVDA, and IVDA was suspected clinically in an
additional 6 (7.5%). The most common isolated microorganism was Staphylococcus aureus, occurring in
50% of patients. Mitral valve lesions were noted in 29% of patients and tricuspid and aortic lesions at
25% and 19% respectively. Multiple valvular lesions were noted in 15% of the cases and the remaining
cases were diagnosed based on other criteria of IE without any definite vegetation. Of the 46 patients
with known IVDA, tricuspid valve vegetations were seen in 15 (33%) whereas lesions on the left sided
(aortic, mitral, or both) were seen in 31 (67%). 18 patients died during hospitalization (22.5%) and 25
(31%) underwent a valve repair or replacement surgery. Cerebral embolism was associated with
increased mortality with an OR 3.33, p=0.03 (95% Cl 1.08-10.25). Patients who died were more likely to
have elevated initial (p=0.014) or peak (p=0.013) troponins than survivors.
Conclusion: Known or suspected IVDA accounted for the majority of endocarditis cases treated at our
institution over a two year period. Contrary to common perception, left sided endocarditis occurred in
the majority of IVDA associated endocarditis cases. Elevated troponins and the presence of cerebral
embolism were associated with higher mortality, and these factors could be useful for identifying
patients with IE who are at higher risk of death.
Jeremy Pollock M.D., Ryan D. Hollenbeck M.D., Quinn Wells M.D., Michael B. Kelley M.D., Chad E.
Wagner M.D., Michael E. Cash M.D., Carol Scott R.N., Kathy Burns R.N., Ian Jones M.D., Joseph L. Fredi
M.D., John A. McPherson M.D.
Objectives: Out-of-hospital cardiac arrest (OHCA) is common and is associated with high mortality. The
majority of in-hospital deaths from OHCA are due to neurologic injury. Therapeutic hypothermia (TH) is
now recommended in the management of comatose survivors of OHCA. The rapid triage and
standardized treatment of OHCA patients can be challenging, and implementation of a TH program
requires a multidisciplinary team approach. We revised our TH protocol and created the “CODE ICE”
pathway to improve the timely and coordinated care of OHCA patients. “STEMI on ICE” integrates TH
with our regional ST-elevation myocardial infarction (STEMI) network.
Methods: Retrospective data were collected on 150 consecutive patients from 2007 to 2011. Subjects
were comatose survivors of cardiac arrest treated with TH. CODE ICE was implemented on May 1,
2010. The primary outcomes were time to initiation of TH and time to reach target temperature, and
the secondary outcome was neurologic function at hospital discharge.
Results: Following implementation of CODE ICE the mean time to initiation of TH decreased from 306
to 196 minutes (p<0.001), and the time to target temperature decreased from 532 to 392 minutes
(p<0.001). There was no significant change in neurologic outcome at hospital discharge.
Conclusions: By implementing comprehensive care pathways including measures such as a burst
paging system and computerized physician support tools, the time to initiation of TH and time to reach
target temperature were significantly reduced. Additional studies are needed to determine the effect of
CODE ICE and similar pathways on clinical outcomes.
Measuring the Effectiveness of the Facilitated Check-In Rounds to Find and Teach
About Diagnostic Errors, Treatment, Care Failures and Stewardship of Resources
First Author: Manuel Lopez Vazquez, MD, James Hanley III MD FACP
Introduction: With the development of the night float shift the internal Medicine Resident has started
to utilize a facilitated check-in to review the overnight admissions by the night float resident. In this
facilitated check-ins; all of the patients admitted by the senior resident are reviewed in detail by a team
of physicians. These details include: transition of care from the ambulatory, through the ER to the
Wards. This examination allows the faculty to identify issues that occur in all settings. This process also
allows real time identification of cognitive diagnostic biases and provides feedback to the residents to
avoid this type of diagnostic erros.
200 consecutive adult patients admitted to the teaching internal medicine service by the night float
internal medicine resident from 7 pm to 7 am. The study includes a chart review and second opinion
analysis performed by our program director, the admitting resident, the teaching service residents, and
hospitalist and general internist working in the service during the time of admission. . ER physicians
were questioned about their diagnostic process including working diagnosis and data to support their
diagnosis as well as their differentials by the admitting resident. Chart reviews were also done at the
moment of admission and at the moment of discharge. Agreement between physicians in different
settings including the outpatient, ED, and the inpatient was measured. Appropiate testing and
antibiotics were determined using ACR appropiateness criteria and IDSA guidelines as well as Sandford
antibiotic guide.
Results: 74% of the total cognitive biased identified ocurred at the ED. The most common cognitive
biased identified was anchoring (38%) followed by premature closure (15%). The ER and Facilitated
Check in Round agreement was 53%. Appropiate Imaging test were done in 92% of the times by ER
physicians and proper antibiotics started by the ER physicians were done in 30% of the times. Hospitalist
and general Internal medicine physicians agreement of diagnosis from admission to discharge was 70%.
Conclusions: The ER is an area of the hospital where a great amount of cognitive biases occur, and
there are different factors involved in their patogenesis. The most common cognitive bias identified and
commited by ER physicians in our institution included anchoring and premature closure. There is a huge
disagreement in diagnosis from the ER to the time of discharge.
For hospitals, diagnostic errors should be an important patient safety issue ironically research in the
area of the diagnostic process has not been developed until recently. This area of patient safety
constitutes an important source of research for the future generations of physicians that understand the
importance of improving their diagnostic skills as part of their own professional development and
specially to protect patients from harm.
First Author: David Thomas Kidwell, MD, MBA Joseph Brading, MD Adam Farber, MD Megan Greene,
MD Austin Metting, MD (Member) Jose Ochoa, MD Jana Reynolds, MD Leena Samuel, MD.
Department of Internal Medicine, Texas A&M Health Science Center / Scott & White Healthcare,
Temple, Texas
Introduction: In an effort to improve the quality of patient care and decrease costs, Scott & White
Healthcare initiated the use of standardized daily renewal orders in 2011 prompting providers to
consider the appropriateness of the ongoing need for urinary catheters, central lines, telemetry and
restraints. A group of internal medicine residents recognized that this form was often not being
completed and sought a way to make the form more valuable to providers, and thus, improve patient
Methods: A team of 7 internal medicine residents designed a quality improvement project introducing
new, value-added daily renewal orders with added sections for “morning labs”, “other orders”, and “lab
holiday” to prompt increased physician use of this form. Patient charts on an inpatient ward at Scott &
White Memorial Hospital were reviewed. A total of 540 charts were reviewed over a total of 18 days.
The first 10 days served as baseline data using the existing daily renewal order form. In the subsequent
8 days, the value-added daily renewal order forms were used. Data was collected using forms
completed by health unit coordinators and a member of the project team. Outcomes of interest
included the number of clarification calls made on orders, total number of daily renewal order forms
needing completion each day, number of completed daily renewal order forms as well as number of lab
holidays. Data was analyzed using Mann-Whitney non-parametric test.
Results: During the first 10-day data collection period using the standard daily renewal order form, 269
charts were analyzed. Of these 269 charts, 160 charts had completed daily renewal orders. During the
second collection period, 219 charts were analyzed with 164 having completed daily renewal orders. A
significant increase in completion of daily renewal orders was observed with use of the value-added
daily renewal order form with mean completion of 74.96%, 95% CI = 72.85-77.07 vs standard renewal
order form completion of 59.56%, 95% CI = 55.79-63.33%, (p value = 0.0004). A non-statisticallysignificant increase in lab holidays was also observed.
Conclusions: A significant increase in completion rates of daily renewal orders was realized through the
addition of value-added components to daily renewal order forms in this resident-initiated quality
improvement project. The institution is planning to continue with this altered daily renewal form. It is
anticipated that these increased completion rates yield improvements in patient care.
Chapter Winning Abstract
Karyne Vinales MD, Alberto O. Chavez MD, Devjit Tripathy MD PhD.
Altered Plasma Glucagon Responses to a Maximal Hyperglycemic Stimulus and Arginine Infusion in
Subjects with Impaired Glucose Tolerance (IGT) and Type 2 Diabetes Mellitus (T2DM) and the Effect of
Pioglitazone, Exenatide, or combination of Exenatide and Pioglitazone on Glucagon secretion.
Karyne Vinales MD2, Alberto O. Chavez MD2, Devjit Tripathy MD PhD1.
Diabetes Division, 2 Internal medicine resident, University of Texas Health Science Center at San
Antonio, San Antonio, TX, USA.
Objective: Although increased basal hepatic glucose production (HGP) in the fasting and impaired
suppression of HGP in the post-prandial state has been attributed to elevated plasma glucagon in T2DM;
the effect of maximal hyperglycemia on suppression of glucagon and non-glycemic (arginine) stimulated
glucagon secretion are not clearly defined.
Methods: We studied NGT (n=15, age=48±4 y, BMI=28±2, HbA1C=5.1±0.1%), IGT (n=23, age=49±2 y,
BMI=33±1, HbA1C=5.8±0.1%), and T2DM subjects (age=55±3 yrs; BMI=35±5; FPG=167±10 mg/dl; HbA1c=
8.3±0.4%) who were randomized to receive: (i) Exenatide (EXE 10ug bid, n=11), (ii) pioglitazone (PIO, 45
mg/d, n=9), or (iii) PIO+EXE (n=9) for 24 weeks. Before and 24 weeks after treatment subjects received
OGTT and 2-step hyperglycemic (+125 and +400mg/dl) clamp followed by IV arginine (5g) bolus. The
acute insulin, C-peptide and glucagon responses during each hyperglycemic step and following arginine
(AIRArg) were assessed and Matsuda Index (MI) of insulin sensitivity was calculated from OGTT.
Results: Acute C-peptide response (ACR0-10) was decreased in IGT vs. NGT (150 ±20 vs. 262±33 ng/ml)
and further reduced in T2DM (46±4 vs. 262±33 ng/ml, p<0.001). During the hyperglycemic second step
AUC80-160 was similar in IGT and NGT (5261±1300 vs. 6282 ±2300 µU/ml), but reduced in T2DM (1105
±250 mU/ml, p<0.001). Glucagon suppression during first step (AUC10-80) was impaired by 60% (-110
pg/ml) in IGT and 70% (-108 pg/ml) in T2DM vs. NGT (-363 pg/ml). In contrast, arginine elicited a greater
increase in glucagon secretion in IGT and T2DM (both p<0.001) vs. NGT. PIO + EXE caused a greater
reduction in FPG, 2-h glucose and HbA1c compared to PIO alone or EXE alone (all p<0.05). Although PIO
was associated with greater increase in insulin sensitivity, there was no difference in hyperglycemiainduced suppression of glucagon secretion or arginine stimulated glucagon secretion between the three
treatment groups.
Conclusion: Regulation of glucagon suppression and release is impaired in IGT, as well as T2DM
suggesting alpha cell dysfunction. The nonexistence of a differential effect of Pioglitazone, Exenatide, or
combination of PIO and EXE on arginine stimulated glucagon secretion suggests a lack of chronic effect
of these drugs on acute hyperglycemia.
The Wright Patterson Garden Clinic: An Experiential Learning and Patient
Empowerment Model toward the Prevention and Control of Diabetes
John Gillis MD (associate), Sarah Fackler MD (member)
Introduction: In diabetes prevention and treatment, patients do not always make healthful changes,
despite possessing a basic understanding of the importance of good nutrition and exercise. The intent of
the study is to evaluate if experiential learning through participation in a community garden will
augment medical therapies targeting the prevention and control of diabetes. Through participation in
the garden and its associated community events, we anticipate patients will show an improvement in
self efficacy, providing the motivation to positively change their lifestyles leading to improved control of
diabetes. In addition they will have access to low-cost healthy food, and gain experiential knowledge of
how to utilize that produce and teach others what they have learned.
Methods: The Garden Clinic is a proof of concept study in which a small population of 10 prediabetic
and 10 diabetic patients were enrolled. Patients were selected from our Group Lifestyle and Balance
classes who had shown a motivation for change but have not yet attained their goals of weight loss and
diabetic control. Patients were asked to contribute at least 5 hours per week to the garden for six
months with an intended total study duration of one year. The initial and midpoint data collection
provided below include: weight, waist circumference, lipid profiles, and a homeostatic model
assessment of insulin resistance.
Results: Initial and midpoint ANOVA comparison
Waist circumference
Fasting insulin
Fasting glucose
Significant change
Yes (p<.001)
No (p=.163)
No (p=.384)
No (p=.103)
No (p=.573)
Average change
-11.81 cm
-6.64 kg
8.5 mmol/L
-4.3 mg/dL
Conclusion: Our midpoint data demonstrate encouraging results in the majority of the categories
above. Although some of the categories are not statistically significant they are clinically significant
(weight loss). The Garden Clinic is a low risk, novel approach to the prevention and control of diabetes
which could provide a low-cost option to strengthen existing treatment modalities.
First Author: CPT Nathan L Boyer, MC USA Second Author: McCarthy, PhD, RN Third Author: Cristin
Mount, MD (Fellow)
Introduction: Controversy regarding the timing and method of enteral feeding in critically ill patients is
an important source of discussion in recent medical literature. Multiple studies have demonstrated early
initiation of enteral feedings in critically ill patients leads to reduced mortality and length of stay.
Current IDSA guidelines support the use of post-pyloric feeding for critically ill patients due to its
association with reduced incidence of hospital acquired pneumonia.
Methods: We conducted a retrospective study examining two different enteral feeding tube systems
available at our institution since 2009 (Tiger tube®, a self advancing feeding system, and Cortrak®, a
magnetic weighted tube with placement visualized in real time). Data obtained included success rate for
post-pyloric placement, congruency of real time tube placement with X-ray confirmation for Cortrak®,
and complication rates. Data analysis was performed using descriptive statistics.
Results: One hundred and twenty seven patient charts were retrospectively studied with forty five and
eighty two patients receiving a Tiger tube® and eighty Cortrak® respectively. The self advancing Tiger
tube® was post-pyloric in 53% (24/45) of initial attempted placements and Cortrak® was post-pyloric in
39% (32/82) of initial attempted placements. When previously recorded live-time Cortrak® tracings
were examined, the tracing accurately reflected placement subsequently confirmed by radiograph 70%
of the time. Two percent (N=1) Tiger Tube® and 8% (N=7) Cortrak®, respectfully, were "unknown" as the
X-ray and Radiologist's report could not determine enteral feeding tube placement. No statistical
difference between the two systems regarding likelihood of post-pyloric location on initial insertion
attempt (p=0.39). The study was underpowered as the projected number need to enroll 200, to find a
statistical difference, was not met. During the entire study period, no patient had inadvertent
endotracheal placement with either tube, and there were no recorded adverse events.
Discussion: Our institution acquired two different post-pyloric enteral feeding tube systems, neither of
which have previously been compared for efficacy. Our preliminary retrospective review, although
limited, implies that both systems are equally effective at post-pyloric placement on first attempt as
there was no significant difference in either system to achieve post-pyloric placement on initial
attempt. Furthermore, the Cortrak® system’s ability to show real time progress of the tube at the time
of placement may be an advantage over the Tiger tube® but discordance between real time tracings and
final position on radiograph warrant final X-ray confirmation of Cortrak® placement.
First Author: Emilio Fentanes, MD (Associate) Second Author: Thomas Wisenbaugh, MD
Background: Quality assurance of a percutaneous coronary intervention (PCI) program is particularly
important when the center volume of procedures is low (<400/yr).
Methods: We searched for predictors of 30-day and long-term incidence of stent thrombosis,
myocardial infarction, need for repeat revascularization, and death from any cause for all PCIs
performed at Tripler Army Medical Center from January 2002 through June 2012. The New York State
Registry (NYSR) regression model was used to compute expected mortality rate based on patient risk
factors. Review of electronic medical records, phone, and mail correspondence was used for follow-up.
Long term results were benchmarked against several large registries.
Results: 929 PCIs were performed in 795 patients, for an average PCI volume of 88/yr. Follow up data
was obtained on 99.8% of patients at 30 days, with a median follow-up of 59 months. Eighteen deaths
occurred prior to hospital discharge or during the first 30-days after PCI, for an unadjusted observed
morality rate (OMR) of 2.26%. Based on the NYSR model our expected mortality was 2.19% (p=0.88,
NS). There was a higher incidence of acutely ischemic and unstable patients compared to NY State
patients. Multivariate logistic regression identified independent predictors of death at 30 days: stent
thrombosis (definite or probable, Odds Ratio 96), acute MI, hemodynamic instability (OR 47), emergent
(OR 17) or salvage (OR 28) PCI , and need for pre-procedural balloon pumping (OR 27). The 30-day
incidence of definite or probable stent thrombosis was 2.6% and the cumulative Kaplan-Meier estimates
were 3.0% at 6 months, 3.4% at 1 year and 4.2% at 3 years, all higher than benchmarks. Furthermore,
since stent thrombosis was such a powerful risk factor for death at 30 days, we searched for and
identified multivariate predictors of stent thrombosis: renal insufficiency (OR 7.15), emergent (OR 6.6)
or salvage (OR 10.3) PCI, proximal LAD stenosis (OR 4.1), number of stents (OR 13.8), and operator (OR
3.7). Long-term survival Kaplan-Meier estimates were 94% at 1 year, 89% at 3 years, comparable to
Discussion: Actual 30-day mortality was similar to expected mortality based on risk factors in the NYSR
model, and long-term survival was comparable to that reported in large registries. Major adverse
cardiac outcomes including stent thrombosis are known to be higher in low volume centers. In our
facility, stent thrombosis was higher than predicted by patient-specific risk factors. Operator-related
factors and the number of stents used per procedure may be modifiable, and have the potential of
improving short term outcomes.
Risk Factors and Subtype Analysis for Extended Spectrum Beta-Lactamase (ESBL)
Producing Escherichia coli and Klebsiella Species with Community-Associated or
Healthcare-Associated Infection Between 2003-May 2011
Michael Koren MD, Steven Mahlen PhD, Samandra Demons PhD, Christina Schofield MD
Background: This study was designed to review the incidence of ESBL-producing Escherichia coli or
Klebsiella species over a 7-year period and compare the risk factors for infection and incidence of CTX,
SHV and TEM ESBL subtypes between patients with community associated (CA) versus healthcare
associated (HA) infection.
Methods: All ESBL isolates between 2003 and May 2011 at Madigan Army Medical center were
evaluated and reviewed. A retrospective chart review assessed for risk factors for infection. True
infection was defined by source with symptoms and culture growth. HA infections were patients with
hospital stay, long-term care facility, surgery or chronic dialysis within 3 months of clinical culture. PCR
with universal primers for TEM, SHV and CTX subtypes was performed. Risk factors for infection, ESBL
subtype and antibiotic susceptibility were compared for HA and CA infection.
Results: A total of 150 unique patient isolates were identified with 28 excluded for not being a true
infection. From 2005 to 2010, the incidence of ESBL in E coli increased from 0.13% to 1.0%, while the
incidence in Klebsiella remained 1.0-1.3%. CA infection was more likely in females (p<0.01), age <60
(p<0.01), urinary source (p<0.01) and recurrent UTIs (p=0.02). 58 isolates underwent PCR and CTX
subtype was more likely to be CA (p=<0.01), E coli (p<0.01) and sensitive to nitrofurantoin (p<0.01); no
susceptibility differences to FQ (34% S) or TMP/SMX (40% S) were present.
Conclusions: This is one of the 1st characterizations of ESBL-producing organisms in the Pacific
Northwest revealing an increased incidence over 7 years particularly in the community setting with
younger females with E coli UTIs of the CTX subtype. Resistance to FQ or TMP/SMX was high in both HA
and CA infection, making the task of appropriate empiric antibiotics more difficult.
Electrocardiogram Competency of Internal Medicine Residents: An Internist’s
Perspective and the Creation of an Assessment Instrument
First Author: Faith Murray, MD Faith R. Murray, Capt, USAF, MC, William N. Hannah, LtCol, USAF, MC,
James A. Watts, MAJ, MC, USA
Introduction: The 12-lead electrocardiogram (ECG) remains one of the most frequently utilized and cost
effective tests for a patient with suspected or known cardiac disease. Accurate ECG interpretation is
essential for the practicing internist. Both the ACGME and ABIM require internal medicine residents to
be competent in 12-lead ECG interpretation for board eligibility. Despite the importance placed on this
skill, the minimum number of electrocardiograms interpreted in order to obtain competency is not
specifically delineated. The 2001 ACC/AHA statement on ECG competency estimated that 500
electrocardiograms read under the supervision of an expert electrocardiographer is sufficient to develop
competency and 100 per year to maintain that competency. Currently, no objective assessment method
for determining competency in ECG interpretation exists for general internists. Our objective is to
develop and validate an instrument that will assess the knowledge and skill level of general internal
medicine residents.
Methods: We constructed a postal survey that was sent to 11 board certified internal medicine
physicians. Participants ranked the clinical importance of 115 different ECG diagnoses using a 5-point
Likert scale with 5 being recognizable to a cardiologist and 1- absolutely must know, failure to recognize
may result in death. A score of < 1.5 was used to define essential for competence and
electrocardiograms with this score were compiled then submitted to three expert
electrocardiographers. Raters were asked to determine the primary diagnosis demonstrated by the
tracing. Electrocardiograms with diagnosis in which the raters disagreed were discarded and those
agreed upon by 2 or more of the cardiologists were included in the assessment instrument.
Results: We received 72% completed surveys from the participants. Twenty eight diagnoses received an
average Likert score of <1.5. Acute myocardial infarction, ventricular tachycardia, AV block, and
hyperkalemia were among the diagnoses deemed essential for identification. There was agreement
between our electrocardiographers on 20 of the 24 electrocardiograms evaluated with 12 of the 24 of
the diagnosis obtaining unanimous agreement.
Conclusion: There was uniform agreement among practicing internists as to which electrocardiographic
diagnosis were essential for interpretation competence, with a clustering of acute critical illnesses
receiving the highest Likert scores. Using the survey data we constructed an assessment instrument
which was then validated by board certified cardiologists, with the long-term goal of determining an
objective benchmark that defines competence for electrocardiographic interpretation for the general
First Author: CPT Henry S Scheuller, MD Other Authors: Allison Abplanalp, PhD, Josue Martinez, PhD,
Capt Charla Tully, DO (Member), and Lt Col Patrick Danaher, MD (Fellow)
Background: Upper respiratory tract illness (URI) is a well-documented cause of morbidity, extra
expense and loss of training among basic military trainees (BMTs).
Methods: Demographic, clinical and laboratory data resulting from the examination of throat and nasal
specimens for respiratory pathogens were collected in a prospective study spanning 01/2005 to 03/2011
among enrolled DOD beneficiaries presenting with URI.
Results: Among 3,842 participants enrolled, 457 (12%) tested positive for influenza by at least 1 of 3
tests in use during the study period: 191 BMTs, 266 non-BMTs. BMTs were younger than non-BMTs (21
v. 35 years). Both groups presented with about 3.5 days of URI symptoms and with similar duration of
sore throat, sinus congestion, cough, and headache. BMTs had fewer days of malaise (1.4v.2.2), fever
(1.7v.2.0), chills (1.5v.2.1), nausea (0.5v.0.9), and vomiting (0.2v.0.4). BMTs had higher temperature at
the time of evaluation (101.4oF v. 100.5oF), lower systolic blood pressure (BP) (120 v. 125), lower
diastolic BP (71 v. 74), and lower body mass index (23.6 v. 26.2). Sensitivity of viral culture differed
significantly when comparing BMTs and non-BMTs: 59% v. 44%. There was no difference in the
sensitivity of polymerase chain reaction (PCR) or enzyme immunoassay (EIA) between the two groups.
Vaccinated individuals spent fewer days with chills (1.7 v. 2). All differences were statistically significant.
Discussion: In general, BMTs with influenza were less symptomatic than non-BMTs, but presented with
a higher fever, as previously reported. This difference may be due to a more robust immune response in
younger populations. Given their status as trainees, response bias may also account for some decrease
in self-reported symptoms. Viral culture performed better in BMTs. This may be due to increased viral
shedding due to their younger age, as has been previously described with RSV. Influenza vaccines may
also aid in reducing symptoms when infected. This reduction, though statistically significant, is not likely
to be clinically significant; the policy of universal influenza vaccination for BMTs is warranted based on
its efficacy of 50-80% in preventing infection, but not on its ability to ameliorate symptoms.
Exploration of a Novel Therapeutic Target in a Murine Model of Systemic Lupus
Erythematosus: Targeting Sphingosine-1-phosphate (S1P) Receptors
First Author: MAJ Christopher L Tracy MD, MC USA MAJ Sharron Frattalone DO LTC Jess Edison MD
Chantal Moratz PHD
INTRODUCTION: Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by
symptomatic flares that often result in terminal organ failure. The pathogenesis is characterized by
complex immune dysfunction, including aberrant T-cell responses. Current therapeutic strategies target
global suppression of inflammation or control of antibody production. Fingolimod (FTY720), an FDA
approved therapy for multiple sclerosis (MS), is a compound with the ability to modulate T-cell
proliferation through S1P receptors. The targeting of infiltrating T-cells in MS by FTY720 suggests it may
be effective in other immune mediated diseases. The aim of this study is to define a subset of S1P
receptors and expression patterns that may be altered in the autoimmune prone ischemic reperfusion
injury(IRI) mouse model.
METHODS: Immune competent (C57BL/6) and autoimmune prone (B6.MRL/lpr) mice were exposed to
FTY720 or Pertussis toxin followed by superior mesenteric artery ischemic reperfusion injury.
Histological analysis of tissue samples was performed to assess tissue injury and the extent of
inflammatory cell infiltration into the injured tissues. Multiplex array based cytokine analysis of isolated
tissue lysates established the extent of induction of inflammatory cytokine production.
Immunohistochemistry analysis of tissue section confirmed the multiplex array analysis.
RESULTS: Targeting the S1P ligands and its G-protein coupled receptor (GPCR) decreased tissue damage
in the autoimmune strain mice compared to the immune competent controls. Targeting the S1P ligands
and its GPCR decreased T-cell infiltration, IL-6 and IL1B levels in the autoimmune prone models
compared to the immune competent controls.
CONCLUSION: Ischemic reperfusion injury results in increased early circulation of T-cells at sites of
inflammation in autoimmune prone mice as compared to immune competent controls. Non-specific S1P
receptor targeting using the receptor agonist FTY720 decreases inflammatory tissue damage, T-cell
infiltration and IL-6 and IL1B levels in the autoimmune mouse model. These findings support the
hypothesis that S1P receptor interaction is a key regulator of T-cell mediated tissue injury and
represents a novel therapeutic target in SLE. Multiple ligands of S1P exist and they exert their cellular
effects through GPCR’s. Specific GPCR targeting with Pertussis toxin, however, resulted in less
modulation of tissue damage in autoimmune prone mice. What remains unclear are the expression
patterns of specific S1P receptors on various states of activation and how that influences the cell
responsiveness during states of inflammation. The goal of future studies will be to find and target
specific receptor ligands responsible for T cell mediated tissue damage in the murine IRI model.
Cutaneous Leishmaniasis and the Efficacy of Azoles, a Systematic Review
LT Wesley R. Campbell, MC, USN (Associate), Glenn Wortmann, COL (Ret), MC, USA, FACP, MAJ Joshua
Hartzell, MC, USA, FACP, LTC Kent Dezee, MC, USA, FACP
Introduction: Cutaneous Leishmaniasis (CL) is endemic to 70 countries with 1.5 - 2 million new cases
occurring annually. The majority of cases occur in the Middle East (Old World) although the disease is
endemic to parts of South America (New World) as well. Travelers and military personnel are at
significant risk of acquiring the disease. Its disfiguring and ulcerative lesions result in a high degree of
morbidity for those infected. Despite the wide spread distribution and number of cases, debate persists
with regard to the most effective treatment for CL. Antimonials have been the mainstay of therapy, but
toxicity and constraints with administering the drug make it difficult to use. In recent years, evidence has
been building regarding the efficacy of azole antifungals. In order to better characterize the
effectiveness of azole antifungals we conducted a systematic review for azole treatment of CL.
Methods: The databases used were MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews.
Search terms included "cutaneous leishmaniasis," "skin leishmaniasis," "therapy," "treatment,"
"fluconazole," "posaconazole," "ketoconazole," "itraconazole," and "voriconazole." The references from
primary studies, narrative reviews and systemic reviews were reviewed to search for additional primary
studies that could have been missed by the electronic search. Two investigators independently screened
all citations by title and abstract and made a decision on acceptance. Disagreements were resolved by a
third author. Inclusion criteria included a confirmed diagnosis of CL, monotherapy with an azole,
availability of azole dosage and duration, at least 2 months of follow-up, and at least 4 patients per
Results: The results of the systematic review will be presented including a breakdown of effectiveness
and side-effects of each azole.
Discussion: The aggregated data supports certain azoles as a choice for treating CL. An alogorithmic
approach to the treatment of CL is provided.
Choosing Wisely Vermont Edition, developing a process to implement Choosing
Wisely principals at Fletcher Allen Health Care
Justin Stinnett-Donnelly MD(1), Patricia Bouchard RN MS CPHQ(1,2) Virginia Hood MBBS, MPH(1) James
M. Jeffords Institute for Quality(2), Fletcher Allen Health Care(1), Burlington VT
Choosing Wisely (CW) is a national campaign launched by the American Board of Internal Medicine
(ABIM) Foundation in April 2012. Initially, 9 medical specialty organizations, including ACP, identified 45
tests or procedures whose necessity is questionable. New specialties have joined the movement and are
developing additional lists. All are working with Consumer Reports, AARP and other consumer-oriented
In 2012, Fletcher Allen Health Care department of medicine (FAHC) began a local CW campaign with a
goal of identifying, measuring and ultimately eliminating low value tests and procedures.
Project Description:
A CW committee requested each medicine subspecialty submit 3 to 5 procedures, tests or treatments
which are consistent with the goals of the national CW campaign. The committee selected 4 projects
which meet the following requirements: 1) The selection must be acceptable to most medicine
physicians, 2) there must be measurement data available electronically for analysis and tracking. 3)
there should be no or minimal increase in physician work load. The first project identified, was from
Nephrology who requested that BUN and creatinine not be ordered for inpatient chronic dialysis
patients (ESRD). Discharge records from July 1, 2010 until June 30, 2012 were reviewed for ICD9 585.6
(ESRD) in any diagnosis field. Once identified all instances of electrolytes, BUN, Cr, Mg, Ca and Phos were
identified. A multi-stakeholder group identified two areas for intervention 1) resident education and 2)
eliminating BUN/Cr from admission order sets if the patient has ESRD as a problem in the EMR (Epic).
720 inpatient hospitalizations were identified with 6320 inpatient days. 97.6% of all discharges had 1
focus lab test ordered. During admission 3951 BUN and 3850 Cr tests were ordered. The Internal
Medicine service was responsible for 56% of Cr tests followed by Surgery (16%) and Family Medicine
(7%).After resident education the usage of BUN/Cr on the target population decreased by 40% in 3
Next Steps:
The EMR intervention of removing BUN/Cr from a admission order sets is currently in development by
our EMR administrators. Once released, we will evaluate the effectiveness of this intervention on
reducing the focus lab testing. In addition, a more comprehensive electronic solution is being sought as
such tests can be ordered by other providers who don’t use the order sets. Conclusions:
We have shown that educating residents on CW initiatives can reduce utilization. However, to
significantly eliminate excess testing we believe an electronic solution and order support is required in
an EMR. This project creates a scalable process model for local implementation of CW principles which
may be applied through an organization based on local idea generation, site specific data analysis and
locally generated solutions.
Peripheral arterial disease is associated with impaired vascular function:
evaluation of vascular endothelial function as a mechanism for compromised
cardiovascular outcomes
First Author: Soroosh Kiani, MD. Aason, J., Holbrook, M.,, Khemka, A., Sharmeen, F., LeLeiko, R.M., Tabit,
C.E., Farber, A., Eberhardt, R.T., Gocke, N., Vita, J.A., Hamburg, N.M.
PURPOSE: Patients with PAD have significantly higher cardiovascular event rates than patients with
established coronary artery disease (CAD) and abnormal endothelial function predicts cardiovascular
risk in PAD. We sought to investigate the relation of peripheral artery disease (PAD) and vascular
METHODS: We evaluated endothelial function in 1,320 patients with combined PAD and CAD (N=298),
PAD alone (N=301), CAD alone (N=391), or controls (age>45 years without CAD or PAD) (N=380).
Measures of endothelial function included brachial artery flow-mediated dilation and digital pulse
amplitude tonometry. Endothelial-independent vascular function was evaluated with nitroglycerinmediated brachial artery dilation. We compared clinical characteristics between the four groups using
one-way ANOVA or Chi-square tests for continuous or categorical data, respectively. We compared
vascular responses across the four groups using one-way ANOVA with post-hoc testing by Tukey’s test.
We performed two multivariable linear regression models comparing the relation of PAD to vascular
function measures. The first adjusted for age, sex, and the presence of CAD. The second additionally
adjusted for clinical covariates and risk factors found to be significantly different across groups
(including black race, diabetes mellitus, hypertension, hypercholesterolemia, smoking history, and
family history of CAD).
RESULTS: Patients with PAD had lower flow-mediated dilation (5.1±3.9% PAD and CAD, 5.8±4.1% PAD
alone) compared to patients with CAD alone (7.2±4.5%) and to controls (8.6±5.2%, P<0.0001). In
multivariable models adjusting for clinical covariates and the presence of CAD, PAD remained associated
with lower flow-mediated dilation (P<0.0001). PAD was associated with lower nitroglycerin-mediated
dilation in unadjusted models but not in models adjusted for risk factors. Patients with both PAD and
CAD had lower digital pulse amplitude tonometry (PAT) ratio in unadjusted models but not in adjusted
models. Flow-mediated dilation was modestly associated with PAT ratio in patients with atherosclerotic
disease (r=0.22, P<0.0001) but not among control participants (r=0.12, P=0.23).
CONCLUSION: Our findings indicate that patients with PAD have greater impairment of vasodilator
function and are consistent with the possibility that endothelial dysfunction may contribute to adverse
cardiovascular prognosis in PAD.
Chapter Winning Abstract
TB or Not TB? Testing Clinician Knowledge Regarding PPD and IGRAs with an Educational Intervention
Joey Parker, DO (Associate); Michael Myint, MD (Fellow)
Virginia Mason Medical Center, Seattle, Washington
Introduction: A patient safety alert (PSA) was filed at our institution after a hospitalized patient with
both radiographic and systemic findings suspicious for active tuberculosis disease was taken off airborne
precautions after having a negative Interferon Gamma Release Assay (IGRA). This patient’s sputum
cultures eventually returned positive for acid fast bacilli and confirmed Mycobacterium tuberculosis, and
several employees were exposed to a patient with pulmonary tuberculosis without airborne
Methods: A study was initiated based on concern for knowledge deficits in clinicians interpreting the
purified protein derivative (PPD) and IGRA tests for both active and latent tuberculosis diagnosis. A
short 9-question, multiple choice survey was distributed to residents, hospitalists, and sub-specialists
related to the PPD and IGRA tests with an emphasis on whether these tests can distinguish active from
latent tuberculosis. Data was gathered and pooled, and a 1-page educational tool was made and
distributed which highlighted core principles regarding the use and limitations of both the PPD and
IGRAs. A 15-minute presentation with similar information was also filmed and made available as online
Results: Findings included significant knowledge deficits in interpretation of PPDs and IGRAs across
training levels and specialties. 33.1% of our 124 respondents felt that IGRA tests can distinguish active
from latent tuberculosis. The pre-test revealed that 56.6% of respondents did not feel comfortable
interpreting PPD and IGRAs, which improved to 25% in the post test.
Conclusion: Understanding of PPD and IGRAs is challenging for many providers, and a targeted risk
assessment and directed education can improve knowledge and use of these tests, and perhaps prevent
unnecessary exposure to potentially deadly pathogens.
Lataifeh, MD
Safety of Clopidogrel in Thoracentesis
A.Lataifeh MD , M.Alourani MD, M.E. Karzoun MD , Y.Shweihat MD ,T.Gress MD, F.Zeid MD
Introduction: Pleural effusion is a common complication of many systemic and pulmonary diseases.
Thoracentesis is indicated for both diagnostic and therapeutic purposes, and the risk of bleeding is
estimated at less than one percent. Due to the prevalence of atherosclerosclerotic diseases clinicians
nowadays encounter more patients requiring thoracentesis that are on active antiplatelet therapy. The
Society of Interventional Radiology, based on expert consensus, recommends continuing clopidogrel in
the periprocedural period. In this study, we investigate the safety of clopidogrel in thoracentesis.
Methods: We retrospectively reviewed all patients undergoing thoracenteses while on active
clopidogrel therapy between June 2009 and June 2012. We collected data on demographics, comorbidities, laboratory studies, radiographic imaging, and mode of guidance (computerized tomography
(CT) versus ultrasound) of thoracentesis. We defined clinically significant bleeding as a drop of more
than 1 g/dl in hemoglobin within 24 hrs of the procedure. The need for transfusion, bloody appearance
of the pleural fluid, worsening of the chest x-ray or the need for chest tube insertion were considered
as additional indicators of significant bleeding. Patients with known congenital bleeding diathesis,
heparin or Coumadin therapy were excluded.
Results: A total of 34 thoracentesis procedures (33 patients) were performed with active clopidogrel
therapy. Two patients (5.8%) developed clinically significant blood loss with an average drop of
hemoglobin of 1.4 g/dl. One of the two patients had bloody fluid appearance. Neither of the patients
needed blood transfusion or surgical intervention. Of note, both patients were elderly males (81 & 85
years) with end stage renal disease (ERSD) on hemodialysis and congestive heart failure (CHF). One of
them was on aspirin and clopidogrel. Overall, thoracentesis was performed under CT guidance in 91% of
cases, including the two patients with significant bleeding.
We found two patients (5.8%) with significant blood loss in our review of 34 consecutive thoracentesis
performed on clopidogrel, a higher bleeding risk than expected based on data reported previously.
Although limited by sample size, lack of a comparison group, and retrospective design, we believe our
findings are concerning. We understand the risk of holding clopidogrel for extended periods, but we are
concerned that continuing therapy may put certain patients at higher risk for bleeding, such as elderly
patients with ESRD and CHF on dual antiplatelet therapy. Ultrasound as the mode of guidance for
thoracentesis may be preferable in higher risk patients given its ability to identify tortuous intercostal
vessels, which cannot be identified on CT. Further prospective studies are needed to evaluate our
Multi-anatomic versus Nasal-only Surveillance Cultures for Detection of MRSA
Colonization among Skilled Nursing Facility Residents
Elizabeth R Duke, MD Christopher J Crnich, MD MS
Introduction: Skilled nursing facilities (SNFs) represent ideal environments for the emergence and
spread of methicillin-resistant Staphylococcus aureus (MRSA). In fact, in recent studies, the prevalence
of MRSA colonization among residents of U.S. SNFs is at least twice as high as that seen among patients
in hospital intensive care units. Detection of asymptomatic MRSA colonization is increasingly used as a
strategy to control the spread of MRSA in healthcare facilities. Most commonly, this is achieved through
culture of the nasal mucosa. However, S. aureus may colonize other body sites. Recent studies, primarily
performed in hospital and clinic settings, suggest that MRSA screening based on nasal cultures alone
may fail to identify a significant proportion of patients colonized with MRSA. Anatomical patterns of
MRSA colonization may differ in the elderly, and the extent to which MRSA screening based on nasal
cultures alone may result in colonization misclassification remains poorly understood. In order to
address this gap in knowledge, we analyzed existing data on patterns of MRSA colonization in SNF
residents to answer the following questions: 1) How often do nasal surveillance cultures fail to identify
MRSA colonization in residents of SNFs? and 2) What combination of culture sites optimally identifies
MRSA colonization status in residents of SNFs?
Methods: 449 residents in in 6 SNFs in South Central Wisconsin were screened for MRSA colonization
using multi-anatomical sampling over a period of up to one year. Consenting subjects were cultured at
the nares, skin of the axilla and groin, skin of their peri-rectal area or a stool specimen, urine in the
presence of an indwelling catheter, the insertion sites of any other invasive devices, and any open
wounds. Resulting cultures were enriched in broth overnight prior to plating on MRSA selective media.
The presence of MRSA was confirmed by standard microbiological techniques. Point estimates and 95%
confidence intervals of the sensitivity for detection of MRSA colonization through culture of a single
body site (e.g., nares) and multiple body sites (e.g., nares and peri-rectal skin) were calculated.
Results: 149 (33%) residents were found to be MRSA positive at one or more body sites on at least one
visit. A nares-only screening approach identified 101 (68%) of colonized SNF residents compared to
screening all body sites. Combining a nasal with a peri-rectal/stool culture identified 131 (88%) of
colonized residents. Combining a nasal with a combined axillary/groin culture detected 127 (85%) of
colonized residents, whereas combining peri-rectal/stool with axillary/groin detected only 93 (62%).
Combining all three culture sites detected 142 (95%) of colonized subjects. Of the seven subjects that
were screen-negative at these three sites, 5 had a wound that was positive for MRSA (and 2 of these
also had devices) and 2 had a device that was positive for MRSA.
Conclusions: Nasal screening fails to identify a significant proportion of SNF residents who are colonized
with MRSA. A multi-anatomical approach to screening, with cultures of nares, peri-rectal skin/stool
versus axilla-groin, and open wounds or devices (if present), appears to be the most sensitive method
for detecting asymptomatic MRSA colonization. Future work will be aimed at determining which
combination of anatomical screens and/or clinical characteristics best predicts persistence of MRSA
carriage, which is known to be a predictor of invasive infection.
ARIZONA · 3, 29, 30, 32
ARKANSAS · 3, 34
MARYLAND · 6, 74, 76
MASSACHUSETTS · 2, 6, 21, 77, 78, 79
MICHIGAN · 6, 7, 80, 81, 82, 84, 85, 87, 88, 90, 91, 92, 93,
MINNESOTA · 7, 95, 96, 97, 98, 99
MISSISSIPPI · 7, 100, 101, 102, 104
MISSOURI · 7, 105, 106, 107
CALIFORNIA · 3, 4, 37, 39, 40, 41, 42, 43, 44, 45, 46
CHILE · 3, 28
COLORADO · 2, 4, 15, 47
NEVADA · 8, 108, 110
NEW JERSEY · 8, 112, 113, 114
NEW YORK · 8, 9, 115, 116, 117, 118, 119, 121, 122, 123,
124, 125, 126
DISTRICT OF COLUMBIA · 2, 4, 17, 48, 49, 50
OHIO · 2, 9, 23, 24, 132, 133, 134, 135, 136
OKLAHOMA · 9, 137, 138
OREGON · 9, 10, 139, 140
FLORIDA · 4, 51, 52, 53
PENNSYLVANIA · 10, 141, 142, 143, 144, 145, 146, 148,
149, 150, 151, 152, 153
PUERTO RICO · 2, 11, 25, 154
GEORGIA · 4, 5, 54, 55, 56, 57
RHODE ISLAND · 11, 156
HAWAII · 5, 59
ILLINOIS · 2, 5, 19, 20, 61, 62, 63, 65, 66, 67
INDIANA · 5, 68, 69
TENNESSEE · 11, 158, 159, 160, 161
TEXAS · 11, 162, 164, 166
KENTUCKY · 5, 70, 71
US AIR FORCE · 11, 167
US ARMY POSTER · 12, 168, 169, 170, 171, 172, 173
US NAVY · 12, 174
VERMONT · 12, 175
VIRGINIA · 12, 13, 176, 178
WASHINGTON · 12, 177
WISCONSIN · 13, 179
American College of Physicians
Abstract Submissions 2013
Associate Vignettes
Table of Contents
Podium Presentations ................................................................................................................................. 27
West Nile Neuroinvasive disease mimicking Amyotrophic lateral Sclerosis ...................................... 28
ILLINOIS PODIUM PRESENTATION - CLINICAL VIGNETTE Samian sulaiman, MD .................................... 29
Is this a true STEMI? ............................................................................................................................ 29
Somatostatinoma presenting as uncontrolled diabetes, hypercalcaemia and weight loss ............... 30
MICHIGAN PODIUM PRESENTATION - CLINICAL VIGNETTE Brijesh D Patel, DO .................................... 31
A thrombus in the Left Anterior Descending Artery after the use of multiple alternative medicines31
MICHIGAN PODIUM PRESENTATION - CLINICAL VIGNETTE Zain I Kulairi, MBChB ................................. 32
Von Willebrand disease and Schwannomatosis----Role of psudogene! ............................................. 32
NEW JERSEY PODIUM PRESENTATION - CLINICAL VIGNETTE Harith A Baharith, MD ............................ 33
Postpartum reversible vasoconstriction syndrome ............................................................................ 33
NEW YORK PODIUM PRESENTATION - CLINICAL VIGNETTE Jennifer Wang, DO .................................... 34
Acute confusional migraine or stroke? ............................................................................................... 34
ELECTROCONVULSIVE THERAPY ......................................................................................................... 35
OHIO PODIUM PRESENTATION - CLINICAL VIGNETTE Oforbuike Ewelukwa, MBBS .............................. 36
A Case of Xanthogranulomatous Cholecystitis Mimicking Gallbladder Cancer .................................. 36
TEXAS PODIUM PRESENTATION - CLINICAL VIGNETTE Jorge Machicado-Rivero, MD ........................... 37
Acute disseminated encephalomyelitis: A rare complication of influenza vaccination ..................... 37
Poster Finalists ............................................................................................................................................ 38
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Kumar Sanam, MD .................................................. 39
Papillary Muscle Rupture with Severe Mitral Regurgitation Following Non-ST Segment Myocardial
Infarction: A Rare Complication .......................................................................................................... 39
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Nilay Kumar, MBBS ................................................. 40
A Young Man with Fever and Eosinophilia ......................................................................................... 40
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Pooja Sethi, MBBS .................................................. 41
The Mystery of Multiple Brain Masses ............................................................................................... 41
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE Jawairia Memon, MBBS .......................................... 42
SURPRISE - SMALL BOWEL EDEMA FROM ACE Inhibitors................................................................... 42
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Mohan Kumar, MD ................................................... 43
An uncommon CAUSE OF cholestatic hepatitis – Epstein Barr Virus.................................................. 43
ALABAMA POSTER FINALIST - CLINICAL VIGNETTE J Matthew R Pierce, MD ....................................... 45
65-year-old female with multiple thromboembolic events................................................................ 45
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Jonathan A Olsen, DO ............................................. 46
Bamboozled by Syncope ..................................................................................................................... 46
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Preethi William, MBBS ............................................. 47
Statins and autoimmune disorders - A less known and potentially fatal association. ....................... 47
ARIZONA POSTER FINALIST - CLINICAL VIGNETTE Razan A El-Ramahi, MBBS ........................................ 48
Gastrointestinal Basidiobolomycosis, An Emerging Fungal Infection In the Southwest USA............. 48
ARKANSAS POSTER FINALIST - CLINICAL VIGNETTE Guru Subramanian Guru Murthy, MD ................. 49
Myocardial infarction .......................................................................................................................... 49
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Jeanne Lee ........................................................... 50
Tick, Tick, Tick: Anaplasmosis in Northern California ......................................................................... 50
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Amanda Lynn Scott, MD ...................................... 51
A Rare Cause of Right Upper Quadrant Abdominal Pain .................................................................... 51
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Ronald Kall, MD ................................................... 52
Tumor Lysis in a Solid Organ Malignancy............................................................................................ 52
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Arta Lahiji, MD ..................................................... 53
A “Queso fresco” conundrum—Acute hepatitis due to Brucellosis ................................................... 53
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Michael R Hubbard, DO ....................................... 54
Cardiopulmonary Bypass And Aortic Balloon Counter-Pulsation In Amniotic Fluid Embolism .......... 54
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Jihane Benhammou, MD ..................................... 55
Aseptic meningitis: A rare presentation of SLE ................................................................................... 55
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Huynh Cao, MD ................................................... 56
Hodgkin Lymphoma: A Novel Treatment Approach ........................................................................... 56
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Sara Patrawala, MD ............................................. 57
LEUKEMIA............................................................................................................................................ 57
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Victoria Taylor Johnson, MD.............................. 59
Hantavirus Pulmonary Syndrome Causing Non-Cardiogenic Pulmonary Edema ............................... 59
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Mark A Lazarus, MD........................................... 60
An Association between Bevacizumab and Recurrent PosteriorReversible Encephalopathy
Syndrome (PRES) in a Patient Presentingwith Deep Vein Thrombosis – A Case Report and Review of
theLiterature ....................................................................................................................................... 60
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Timothy J Maarup, MD ...................................... 61
A Fatal Course of Fever of Unknown Origin........................................................................................ 61
CALIFORNIA POSTER FINALIST - CLINICAL VIGNETTE Brandon L Nathaniel, MD .................................. 62
Amebic liver abscess presenting as aliver mass in Southern California.............................................. 62
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Allison K Nitsch, MD ............................................. 63
In the Blink of an Eye: Rapid Progression of Syphilis in a Patient with HIV ........................................ 63
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Brian Petersen, MD .............................................. 64
Topical Tacrolimus-Associated Eczema Herpeticum Exacerbated by Prednisone – A Case Report ... 64
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Ben R Mendoza, III MD ......................................... 65
RUNNER WITH A RACING HEART ........................................................................................................ 65
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Brittany R Folks, MD ............................................. 66
An uncommon route for an uncommon pathogen ............................................................................ 66
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Michael Benoit, MD .............................................. 67
Pseudohypobicarbonatemia, A False Truth About Acidemia. ............................................................ 67
COLORADO POSTER FINALIST - CLINICAL VIGNETTE David Johansen, MD ............................................. 68
Telaprevir Induced Urate Nephropathy .............................................................................................. 68
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Jennifer Y Wu, MD ................................................ 69
Ataxia, Headache and Altered Mental Status: a case of neuro Behcet's ............................................ 69
COLORADO POSTER FINALIST - CLINICAL VIGNETTE Hannah M Hall, MD .............................................. 70
Apical Hypertrophic Cardiomyopathy, a BENIGN Form of Heart Disease? ........................................ 70
COLORADO POSTER FINALIST - CLINICAL VIGNETTE David P Theis, DO ............................................... 71
"Whole Body Rash: Differential Diagnosis on a 'Large Scale'" ............................................................ 71
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Megan S Lemay, MD ........................................ 72
Waiting For a Liver and Smoking Marijuana: Stuck in the Weeds. ..................................................... 72
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Ranjit Joseph, MD ............................................ 74
Hemophagocytic Lymphohistiocytosis: A Diagnostic and Therapeutic Dilemma in the Critical Care
Setting ................................................................................................................................................. 74
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Fady Hannah-Shmouni, MD ............................ 75
Leonine Facies in a Man with Recurrent T-Cell Large Granulocytic Leukemia ................................... 75
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Shine Raju, MD ................................................ 76
Acute Aortic Thrombus With Distal Limb Ischemia As The Initial Presentation Of Acute Myelogenous
Leukemia ............................................................................................................................................. 76
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Amrita R John, MD,MBBS ................................ 77
A puzzling case of Mycobacterium abscessus..................................................................................... 77
CONNECTICUT POSTER FINALIST - CLINICAL VIGNETTE Rajany V Dy, MD ............................................ 78
The Many Facets of IgG4-Related Disease .......................................................................................... 78
DELAWARE POSTER FINALIST - CLINICAL VIGNETTE Donald F Slack, III MD ......................................... 79
A Poisonous Remedy: Abdominal Colic and Herbal Supplement Use ................................................ 79
IL-6 Inhibition as Initial Therapy in non-HIV-associated Multicentric Castleman Disease ................. 80
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Aaron B Heath, DO .................................................... 82
TNF inhibitor associated Kikuchi-Fujimoto disease ............................................................................ 82
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Jerson Munoz Mendoza, MD .................................... 83
TOO MANY CYSTS IN THE LUNG WITH AN UNCOMMON CULPRIT ..................................................... 83
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Seetha Lakshmi, MD ................................................. 84
Title and Author Information: Chronic cystitis: Is this in your differential? Cardona Lyssette
MD,Srivastava Alok MD,Seetha Lakshmi MD...................................................................................... 84
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Johanna P Daugherty, MD ........................................ 85
The Way to a Woman’s Brain is through her Belly? ........................................................................... 85
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Vikas Khullar, MD ...................................................... 86
The Malignant Truth about Hypercalcemia ........................................................................................ 86
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Sandra Rodriguez, MD .............................................. 87
A rare association between active Ulcerative Colitis and immune thrombocytopenia ..................... 87
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Meghan M Harris ...................................................... 88
The Lonely Platelet: A Case of Refractory Thrombocytopenia in a patient with long history of ITP .. 88
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Jasmin Martinez, MD ................................................ 89
A Thorn In The Duodenum: A Rare Complication of IVC Filter Placement ......................................... 89
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Jennifer L Horsley-Silva, MD ..................................... 90
Diabetic Ketoacidosis in a Non-Diabetic Patient................................................................................. 90
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Tulisa Hanflink LaRocca, MD ..................................... 91
A Rare Case of Sclerosing Mesenteritis .............................................................................................. 91
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Julietta Militello, DO ................................................. 92
B-Cell lymphoma presenting as a pathological fracture ..................................................................... 92
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Carolina Mejia, MD ................................................... 93
An unusual cause of abdominal pain in a young patient with SLE: The hidden target....................... 93
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Leyla V Maric, MD ..................................................... 94
Hemorrhagic Form of Crohn’s Disease ............................................................................................... 94
FLORIDA POSTER FINALIST - CLINICAL VIGNETTE Morganna L Freeman-Keller, DO ............................ 95
Cannabis Hyperemesis Syndrome: An Emerging Cause of Intractable Nausea and Vomiting ........... 95
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Pratik Mukund Choksy, MBBS.................................. 96
Significance of ST elevation in Often Overlooked Lead aVR ............................................................... 96
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Meghan M Lyman, MD ............................................ 97
Hyponatremia: the cause or the effect of altered mental status? ..................................................... 97
GEORGIA POSTER FINALIST - CLINICAL VIGNETTE Jonathan D Gardner, MD ....................................... 98
Dofetilide-Induced Torsades de Pointes in a Patient with Takotsubo Cardiomyopathy .................... 98
HAWAII POSTER FINALIST - CLINICAL VIGNETTE Sarah M Gordon, MD................................................ 99
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Marco A Paez, MD ................................................... 100
Sulfasalazine Induced DRESS syndrome: A clinical case ................................................................... 100
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Jae Cho, MD ............................................................. 101
Right Main Pulmonary Artery Thrombus After Type A Aortic Dissection Repair ............................. 101
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Vishnu Vandana Palle, MD ...................................... 102
Two Rare presentations of Wegener's granulomatosis-Digital gangrene and Omental hemorrhage
.......................................................................................................................................................... 102
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Swati Gulati, MBBS .................................................. 103
CHRONIC HEADACHE CAN BE A DIAGNOSTIC HEADACHE !!! ........................................................... 103
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Lokesh R Shahani, MD ............................................. 104
Infections in asplenic patients .......................................................................................................... 104
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kovid Trivedi, MBBS................................................. 105
Pulmonary Blastomycosis: A Challenging Diagnosis In Difficult Scenario......................................... 105
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Suneel Kumar, MD ................................................... 106
I CAN’T BREATHE DOC…AND …!! ...................................................................................................... 106
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Snigdha Kola, MBBS ................................................. 107
Hypercalcemia, A harbinger of pathologic disequilibrium! The Butterfly effect? ............................ 107
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Vaishnavy Bhaskaruni, MBBS .................................. 108
Speechless Extubation!-A case report of bilateral hypoglossal nerve paralysis following extubation.
.......................................................................................................................................................... 108
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Pakhadi H Buddhadev, MBBS .................................. 109
Coma: Hyperthyroid or Hypothyroid? .............................................................................................. 109
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Roel Conrad E Jamis, MD ......................................... 110
Pulmonary Nocardiosis: An Opportunistic Infection Not to be Missed ............................................ 110
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Abhijai Singh, MD .................................................... 111
An uncommon cause of lytic lesions of the skull .............................................................................. 111
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Dima Dandachi, MD ................................................. 112
How complete is your physical exam? .............................................................................................. 112
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Muhammad Toor, MBBS ......................................... 113
Most common form of rare coagulation factor deficiencies ............................................................ 113
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Shobha Shahani, MD ............................................... 114
The Perilous Pearl ............................................................................................................................. 114
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Salih Samo, MD ........................................................ 115
Thymoma Can Be As Nasty As This! .................................................................................................. 115
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Sangeeta Juloori, MBBS ........................................... 116
MAY THURNER SYNDROME .............................................................................................................. 116
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Naseem A Ghazanfari, MD ...................................... 117
Severe Cobalamin Deficiency: A case illustrating the diagnostic pitfalls .......................................... 117
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Radhika Kothakota................................................... 118
A puzzling ascites in a blind man on hemodialysis ........................................................................... 118
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Arun Singavi ............................................................. 119
Right Heart Failure and Hypoxia in Hereditary Hemorrhagic Telangiectasia ................................... 119
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Idelle Fraser, MD ..................................................... 120
An Unusual Case of Low Output Heart Failure as the Initial Presentation of Hyperthyroidism ....... 120
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Rena A Shah, MD ..................................................... 121
Two Rare Complications of One Common Chemotherapy Agent .................................................... 121
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Indrajeet Mahata, MBBS ......................................... 122
Concurrent primary lung cancer of different histological types ....................................................... 122
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Adnan Khan, MD ...................................................... 123
Myocardial Infarction Is Not the Only Cause of Chest Pain. ............................................................. 123
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Maryam Gul, MBBS.................................................. 124
Million dollar workup! Not always a waste.. .................................................................................... 124
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Radha Devi Radhakrishna Pillai, MD ........................ 125
Eat more yet feel weak ..................................................................................................................... 125
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Sathish Kumar Krishnan, MD ................................... 126
Lung Mass And Pleural Effusion – Planning For A Biopsy? Test The Urine Before That!.................. 126
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Kalyani Chandra, MBBS ........................................... 127
Rash with Pulmonic Valve Vegetation: A Rare Case of Disseminated Gonococcal Endocarditis ..... 127
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Atena Lodhi, MD ...................................................... 128
Pyogenic liver abscesses: manifestations and management of an evolving pathogen .................... 128
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Bonnie Wang, MD .................................................. 129
Dramatic Intracerebral Hemorrhagic Presentations of Reversible Cerebral Vasoconstriction
Syndrome: three cases and literature review ................................................................................... 129
ILLINOIS POSTER FINALIST - CLINICAL VIGNETTE Izabela Postacchini, MD ......................................... 130
Multiple Myeloma Within The Liver ................................................................................................. 130
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Anita Rajagopal, MD ............................................... 131
More Than Just Your Typical Back Pain-An Unusual Presentation of Diffuse Large B Cell Lymphoma
.......................................................................................................................................................... 131
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Kartik Shatagopam, MD .......................................... 132
Fever and rash without localizing symptoms ................................................................................... 132
INDIANA POSTER FINALIST - CLINICAL VIGNETTE Sean M Teagarden, DO ......................................... 133
B12 Deficiency from Carcinoid? ........................................................................................................ 133
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Nabil M Mansour, MD.............................................. 134
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Sapna A Shah-Haque, MD ........................................ 135
IMMUNOCOMPETENT MALE. ........................................................................................................... 135
KANSAS POSTER FINALIST - CLINICAL VIGNETTE Maya Estephan, MD ................................................. 136
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Bharat Kumar, MD ............................................... 137
Autoimmunity Loves Company ......................................................................................................... 137
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Nirmanmoh Bhatia, MD ....................................... 138
Sumatriptan Induced Hypertensive Episodes Presenting As Pseudophaeochromocytoma ............ 138
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Diego Alcivar Franco, MD .................................... 139
Carcinoid syndrome, a heart disease ................................................................................................ 139
KENTUCKY POSTER FINALIST - CLINICAL VIGNETTE Eric C Wilkerson, MD ......................................... 140
Wellens' Syndrome: Critical to Recognize ........................................................................................ 140
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Ali Baghian, MD ................................................... 141
A Double Whammy Fungal Sphenoid Sinusitis with Cranial Nerve Palsy ......................................... 141
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Yasin Khan, MD ................................................... 142
Rapidly developing endocarditis and recurrent septic arthritis in a patient with Abiotrophia
bacteremia ........................................................................................................................................ 142
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Tracey L. Henry, MD MPH MS ............................. 143
The New AIDS Chameleon?............................................................................................................... 143
LOUISIANA POSTER FINALIST - CLINICAL VIGNETTE Abhishek Seth, MD .............................................. 144
MAINE POSTER FINALIST - CLINICAL VIGNETTE Elizabeth Laura Herrle, MD ........................................ 145
A Little Short of Breath: A Case of Cardiac Tamponade from an Uncommon Cause ....................... 145
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Michael G Allison, MD ...................................... 146
A Case of Gadolinium-Induced Kounis Syndrome ............................................................................ 146
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Namrata P Shah, MD ........................................ 147
Doc! There is something in my eye! ................................................................................................. 147
A Suffocating Bleed ........................................................................................................................... 148
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tarik Anatoli Phillip, MD .................................... 149
What Happened To My Hands and Feet? A Case of Hand Foot Syndrome ...................................... 149
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Shauna S Morrow, MD .................................... 150
AIDS Masquerading as Dermatomyositis: Underscoring the Importance of Sexual History ............ 150
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Amanda M Horne, MD ..................................... 151
A Sheep in Wolf’s Clothing: A Case of Pseudovasculitis ................................................................... 151
MISSOURI POSTER FINALIST - CLINICAL VIGNETTE Shariq Shamim, MD ............................................ 152
Meningoencephalitis: A rare presentation of undiagnosed Adult Still’s Disease ............................. 152
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Zeinab I El Boghdadly, MBBCh........................... 153
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE James L Gentry III, MD ........................... 154
Death Delusions and Myoclonus in a Dialysis patient with multi-dermatomal Herpes Zoster: a
consequence of disease or treatment? ............................................................................................ 154
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Ujjval Jariwala, MD ............................................. 155
Takotsubo (Stress-induced) Cardiomyopathy in an incarcerated patient presenting with methadone
withdrawal. ....................................................................................................................................... 155
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Talha Abdul Rehman Meeran, MBBS ................. 156
IL2 induced AV Dissociation .............................................................................................................. 156
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Svetlana Chembrovich, MD ................................ 157
Ovarian Hyperstimulation Syndrom ................................................................................................. 157
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE George Kunnackal John, MD .............................. 158
Severe Pain Localized to 8 Inches in the Leg: A Case of Diabetic Muscle Infarction ........................ 158
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Rupali N Sangrampurkar, MBBS ......................... 159
Myeloid versus Lymphoid – a case of Biphenotypic Acute Leukemia .............................................. 159
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Rohit K Jain, MD ................................................. 160
Paraneoplastic neurological syndrome due to occult fallopian tube carcinoma ............................. 160
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Rutul J Dalal, MBBS ............................................ 161
An Unusual case of bilateral Cryptococcal Choroiditis in an AIDS Patient with Disseminated
Cryptococcal Infection ...................................................................................................................... 161
MARYLAND POSTER FINALIST - CLINICAL VIGNETTE Ruby Gupta, MD ................................................. 162
Purulent pericardial tamponade due to Staphylococcus infection in a patient with Human
Immunodeficiency virus .................................................................................................................... 162
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Hassan Ziud ............................................... 163
STILL’S DISEASE IS STILL THERE ......................................................................................................... 163
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Francisco J Hernandez Munoz .................. 164
“The worse headache of my life”: Parasitemic in New England ....................................................... 164
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Sandeep Somalaraju, MD ......................... 165
Vasospasm from 5-fluorouracil - A Kounis Syndrome ? ................................................................... 165
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Indumathy Varadarajan, MBBS ................ 166
Can Genital lesions cause chest pain? .............................................................................................. 166
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Rattanaporn Mahatanan, MD .................. 167
Human Babesiosis: A case series from suburban Massachusetts..................................................... 167
MASSACHUSETTS POSTER FINALIST - CLINICAL VIGNETTE Karthik Gnanapandithan, MD ................... 168
Gastro-Esophageal Reflux and Pulmonary Fibrosis: A Long Term Relationship ............................... 168
Unusual presentation of Cardiobacterium hominis endocarditis..................................................... 169
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aaron C Roberts, MD ........................................... 170
Jod-Basedow phenomenon in patient with Graves’s disease visiting from an iodine deficient region
.......................................................................................................................................................... 170
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Faris El-Khider, MBBS .......................................... 171
An Unusual Presentation of Stenotrophomonas maltophilia ........................................................... 171
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Michael Burton, MD ............................................ 172
Severe Hypereosinophilia Secondary to a Dialyzer Reaction ........................................................... 172
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Syeda Hina Batool, MD ........................................ 173
A rare case of fulminant hepatic failure in the setting of radiographically silent metastatic liver
disease .............................................................................................................................................. 173
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Maha Alhusseini, MD........................................... 174
The Importance of Early Recognition of a Novel Monoclonal Antibody Adverse Events ................. 174
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Roopkiranjot K Kahlon, MD,MBBS ....................... 175
Thrombocytopenia-Did you look at the slide?.................................................................................. 175
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Muhammad Salman Sadiq, MBBS ....................... 176
CANNABIS HYPEREMESIS SYNDROME .............................................................................................. 176
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Sourabh Aggarwal, MBBS .................................... 177
Displacement of Impella post chest compressions – Necessity of vigilance .................................... 177
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Aubrey N Schmidt, MD ........................................ 178
Unsuccessful Suicide Attempt: A Remarkable Recovery from Depakote Poisoning ........................ 178
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Samer Kanno Sr, MBChB...................................... 179
Unusual presentation of Hypothyroidism......................................................................................... 179
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tania Jain, MBBS.................................................. 180
Pellagra dermatitis in a patient with carcinoid ................................................................................. 180
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Imad Bagh, MD .................................................... 181
Hemophagocytic lymphohistiocytosis in Infliximab -associated Disseminated Histoplasmosis. ..... 181
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Karim Al Azizi, MD ............................................... 182
Pseudomyxoma Peritonei as a rare cause of abdominal pain in a 62 year old female .................... 182
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Syed A Hussain, MD ............................................. 183
Atypical Presentation of Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV patient .... 183
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Salwa Hussain, MBBS........................................... 184
Bortezomib induced Hepatitis B reactivation: a unique phenomenon ............................................ 184
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Alpesh K Korant, MD............................................ 185
Cannabis: An uncommon Cause of Myocardial Infarction in a Young Patient? ............................... 185
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Rizwan Khan, MD ................................................. 186
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Adeeb Bulkhi, MD ................................................ 187
A 62-year-old male with progressive dyspnea and dry cough .......................................................... 187
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Sudarshan Paudel, MBBS..................................... 188
Stenting for an intrasellar mass ........................................................................................................ 188
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Alaa Abu-Sayf, MD ............................................... 189
A Rare Case of Idiopathic Collapsing Focal Segmental Glomerulosclerosis That Responded to Steroid
Treatment ......................................................................................................................................... 189
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Barryton Decruse Waanbah, MD......................... 190
Actinomyces israelii Masquerading As An Intercostal Sarcoma In A Low Risk Patient .................... 190
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Shaheer Zulfiqar, MD ........................................... 191
A Case of Unusually Aggressive Evans Syndrome ............................................................................. 191
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Brijesh D Patel, DO .............................................. 192
Asymptomatic Complete Heart Block: Can one survive without impulse conduction? ................... 192
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Sayf M Al-Tabaqchali, MD ................................... 193
Urgent Filter-Protected Thrombectomy and Percutaneous Angioplasty with Stent for Acute
Vertebral Artery Thrombosis and Stenosis ....................................................................................... 193
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Amy H Attaway, MD ............................................ 194
Medications that leave spots. Bullous Pemphigoid and Dipeptidyl Peptidase IV Inhibitors: A Case
Report and Review of Literature. ...................................................................................................... 194
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Adaeze C Okafor, MD .......................................... 195
Renal Infarct As Initial Presentation of Atherosclerotic Disease ...................................................... 195
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Asad Omar, MD ................................................... 196
Incidental Finding of Severe Hypoxia in an Asymptomatic Patient Caused by Pulmonary
Arteriovenous Malformations .......................................................................................................... 196
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Jaya S Edukulla, MBBS ......................................... 197
Eosinophilic Pneumonia, Rare but fatal side effect of Daptomycin: A case report .......................... 197
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Maryconi M Jaurigue, MD ................................... 198
“Don’t Touch My Neck”: A Case of Internal Carotid Artery Dissection Presenting With Painful
Horner’s Syndrome After Chiropractic Manipulation ....................................................................... 198
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Raza Abbas, MBBS ............................................... 199
A unique case of non-AL cardiac amyloidosis associated with plasma cell dyscrasia ...................... 199
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Sana Syed, MBBS ................................................. 200
A Case of Pustular Psoriasis .............................................................................................................. 200
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Leonid Shamban, DO ........................................... 201
Aluminum Saftey in End Stage Renal Disease ................................................................................... 201
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Zaid Kasmikha, DO ............................................... 202
A Rare Case of Intracystic Papillary Carcinoma of the Breast in a Male ........................................... 202
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Timothy R Larsen, DO .......................................... 203
A Clinical Surprise; Severe Myocardial Hypertrophy With Apical Blood Stasis, Cardioembolic Stroke,
and Ventricular Tachycardia ............................................................................................................. 203
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Inder S Tandon, MD ............................................. 204
"A diagnosis hidden in a puff of smoke" Pseudobulbar Palsy Secondary to Stroke in a Patient with
Moyamoya Disease ........................................................................................................................... 204
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Charlotte E Wiemann, MD................................... 205
Pericardial Cysts: Supporting the Treatment Paradigm .................................................................... 205
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tezo Anto Karedan, MD....................................... 206
A Rare Case Of Male Breast Sarcoma ............................................................................................... 206
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE George T Dunham, MD ........................................ 207
Myelodysplastic Syndrome, Constipation, and Neuralgia…Adult Plumbism? .................................. 207
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Tessa Marcelle B Antalan, MD ............................. 208
Rituximab-Induced Subacute Tumor Lysis Syndrome in a Patient with Chronic Lymphocytic
Leukemia ........................................................................................................................................... 208
MICHIGAN POSTER FINALIST - CLINICAL VIGNETTE Mohammed Omer Ali, MD .................................. 209
Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation . 209
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Badr F Al-Bawardy, MD ..................................... 210
A Case of Reccurent Ascites and Peripheral Neuropathy ................................................................. 210
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Aditya P Devalapalli, MD................................... 211
Colonic Telangiectasias as Cause for Severe Gastrointestinal Hemorrhage in CREST Syndrome .... 211
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Rahma M Warsame, MD .................................. 212
Not your Typical Headache ............................................................................................................... 212
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Kavel H Visrodia, MD ........................................ 213
An Unusual Case of Intractable Nausea and Vomiting ..................................................................... 213
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Brianna E Vaa, MD ............................................ 214
Intravascular Hemolysis, as a Presenting Feature of Acute Cytomegalovirus Infection .................. 214
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Bradley W Anderson, MD ................................. 215
MRI Termination: Rise of the Machines ........................................................................................... 215
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Melissa A Wells, MD ......................................... 216
Influences of the heart: Cardiac involvement in inflammatory myopathy....................................... 216
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Daniel K Chan, MD ............................................ 217
Eustachian Valve Endocarditis: An Uncommon Syndrome with a Common Association................. 217
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Jasmine R Marcelin, MD ................................... 218
Acute disseminated histoplasmosis after adalimumab (Humira) therapy for psoriatic arthritis ..... 218
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Hugo Botha, MD ............................................... 219
Differentiating atrial masses can be challenging. ............................................................................. 219
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Harmony L Tyner, MD ....................................... 220
Diagnosing Tuberculous Meningitis: The Specificity of Suspicion .................................................... 220
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Gregory P Kaufman, MD ................................... 221
A Rare Infectious Complication Following Allogeneic Hematopoietic Cell Transplantation (HCT) .. 221
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Kimberly N Harer, MD....................................... 222
Eosinophilic Gastroenteritis: not always from allergy ...................................................................... 222
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Hemang Yadav, MBBS....................................... 223
Actinomyces Lung Abscess As A Possible Infectious Trigger For Granulomatosis With Polyangiitis: A
Case Report ....................................................................................................................................... 223
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Suparna Chandra, MD ....................................... 224
Hidden in the Heart: Complementary Imaging Modalities in Investigating in Metastatic Melanoma
.......................................................................................................................................................... 224
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Ruth E Bates, MD .............................................. 225
Recurrent Oral Ulcerations ............................................................................................................... 225
MINNESOTA POSTER FINALIST - CLINICAL VIGNETTE Saurabh Sharma, MD ........................................ 226
Vancomycin Induced Thrombocytopenia: an upcoming entity. ....................................................... 226
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Kamel A Gharaibeh, MD ..................................... 227
HYPOTHYROID ? AN ILLUSTRATIVE REPORT OF TWO CASES. ........................................................... 227
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Brett A Bennett, MD .......................................... 228
Knot on the Head: The Rare Occurrence of Metastatic Colon Cancer Presenting as Temporal
Swelling and Headache ..................................................................................................................... 228
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Sumaira M Malik, MD ........................................ 229
Eculuzimab in a case of severe and refractory Hemolytic uremic syndrome (HUS)......................... 229
MISSISSIPPI POSTER FINALIST - CLINICAL VIGNETTE Adesh D Patel, MD ............................................. 230
Chest Pain: A common symptom with an uncommon etiology. ...................................................... 230
NEBRASKA POSTER FINALIST - CLINICAL VIGNETTE George Mansour, MD .......................................... 231
Rare Malignancy with Metastasis 16 Years Following Primary Resection........................................ 231
NEBRASKA POSTER FINALIST - CLINICAL VIGNETTE Adegboyega O Olayode, MBBS ............................ 232
Atypical Presentation of Celiac Disease ............................................................................................ 232
NEBRASKA POSTER FINALIST - CLINICAL VIGNETTE Abhilash Akinapelli, MBBS ................................... 233
Unexpected Complication Following Video-Assisted Thoracic Surgery............................................ 233
NEBRASKA POSTER FINALIST - CLINICAL VIGNETTE Manar Y Suker, MD ............................................ 235
Pulmonary Edema Secondary to Diuretics Therapy ......................................................................... 235
NEVADA POSTER FINALIST - CLINICAL VIGNETTE Kasaiah Makam, MBBS............................................ 236
Potential Lethal complication following TEVAR (Thoracic EndoVascular Aneurysm Repair) ........... 236
NEVADA POSTER FINALIST - CLINICAL VIGNETTE Faisal M Siddiqui, MD ............................................ 237
NEW MEXICO POSTER FINALIST - CLINICAL VIGNETTE Leona Y Ebara, MD ........................................ 238
An unusual causeof pneumothorax and empyema .......................................................................... 238
NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE Arjun D Iyengar, MD ............................... 239
NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE Arjun D Iyengar, MD ................................. 240
Antiplatelet therapy as a suspected cause of spontaneous intracranial bleed, AN EVIDENCE BASED
REVIEW.............................................................................................................................................. 240
NEW HAMPSHIRE POSTER FINALIST - CLINICAL VIGNETTE Sung-hee Choi, MD ................................... 241
Primary Acute Pericardial Disease as First Manifestation of Malignancy: A Case presenting with
Syncope ............................................................................................................................................. 241
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vikram Doraiswamy .......................................... 242
Paroxysmal Nocturnal Hemoglobinuria (PNH): How often we miss this diagnosis? ........................ 242
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Alina Basnet ...................................................... 243
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Parasuram Krishnamoorthy, MBBS................... 244
SMOKING SPICE? KIDNEYS DON'T LIKE IT. ........................................................................................ 244
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Vishwanath Pattan, MBBS ................................ 245
Acute Retroviral Syndrome-a major diagnostic dilemma ................................................................. 245
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Narsimha Reddy Candula, MD .......................... 246
Myeloid Sarcoma: An Unusual Cause of Spinal Cord Compression .................................................. 246
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Kalpana M Nagarkar ......................................... 247
Man, Mind and Madness! ................................................................................................................. 247
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Anjali Majumdar, MD ........................................ 248
Immunosuppression leading to an infectious triple threat .............................................................. 248
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Shauhab T Chaudhry ......................................... 249
Testicular and Kidney Masses in an HIV-Infected Man..................................................................... 249
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Haobin Chen, MD .............................................. 250
Spinal Cord Compression Caused by Hypertrophic Pachymeningitis: A rare presentation of IgG4related disease .................................................................................................................................. 250
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Jennifer C Kam, MD........................................... 251
A Hemodialysis Patient with an Unusual Abdominal Film ................................................................ 251
NEW JERSEY POSTER FINALIST - CLINICAL VIGNETTE Elias Akl, MD ..................................................... 252
A case of interventricular fistula after HACEK Endocarditis ............................................................. 252
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Wonnqarm Kittanamongkolchai, MD ................. 253
An interesting cause of polyneuropathy in dialysis patient. Is it rare or overlooked? ..................... 253
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Mamta Chhetri, MD ............................................ 254
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sravanthi Nandavaram, MD ................................ 255
Herpes Lurking In The Ganglion : Rare Cause Of Urinary Retention ................................................ 255
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Katie Kwaschyn ................................................... 256
The Case of the Lymph Nodes That Vanished in the Operating Room ............................................. 256
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Aakash Aggarwal, MBBS...................................... 257
Isolated PTH Renal Resistance: A rare cause of hypocalcemia ......................................................... 257
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Leena K Pawar, MD ............................................. 258
34 year old female with Muir-Torre Syndrome –A case report ........................................................ 258
Idiosyncratic Febrile Neutropenia Associated with Quetiapine and Levetiracetam ........................ 259
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Beata A Kaczkowska, MD .................................... 260
Anomalous Aortic Origin of Coronary Artery and Sudden Cardiac Death: Consideration of Diagnostic
and Treatment Approaches. ............................................................................................................. 260
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Peter Abdelmessieh, DO ..................................... 261
liraglutide Induced Pancreatitis ........................................................................................................ 261
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Syeda A Batul, MBBS ........................................... 262
Coexisting Pulmonary Necrobiotic Nodules and ANCA-positive vasculitis in a patient with Crohn’s
disease-An unusual presentation ..................................................................................................... 262
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sameer Chadha, MBBS ........................................ 263
Broken Taxes, Broken Heart ............................................................................................................. 263
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Cesar E. Orellana, MD ......................................... 264
Keep Whipple’s Disease in Mind: A Rare Clue to Neuro-Whipple .................................................... 264
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Richa Aggarwal, MBBS ........................................ 265
EUGLYCEMIC DIABETIC KETOACIDOSIS ............................................................................................. 265
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Naveen K Yarlagadda, MD ................................... 266
Vancomycin intermediate Staphylococcus aureus (VISA): An emerging new super bug ................. 266
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sowmya Korapati, MBBS ..................................... 267
WHAT IS UNSOUGHT WILL GO UNDETECTED ................................................................................... 267
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Mahrukh S Rizvi, MD ........................................... 269
Gasps and facial swellings: A lurking diagnosis................................................................................. 269
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Priya K Simoes, MD ............................................. 270
Not the Usual Pulmonary Embolism ................................................................................................. 270
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Waseem Chaudhry, MD ...................................... 271
Spontaneous healing of a severe (F-type) coronary artery dissection ............................................. 271
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Amitpal Nat, MD.................................................. 272
H.Pylori: A Benign and Malignant Cause of Gastric Outlet Obstruction ........................................... 272
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Hashim Nawaz Deen, MD .................................. 273
“Tick”- Tock, “Tick”-Tock – How Lyme Disease Can Stop the Heart ................................................. 273
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Sahil Agrawal, MBBS .......................................... 274
Clopidogrel: A cause of recurrent rheumatism? ............................................................................... 274
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Michael Goyfman, MD ...................................... 275
TUBERCULOSIS. ................................................................................................................................. 275
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Aditya Vuppala, MBBS ....................................... 276
Killer Foley: Opening a Fatal Pandora’s box. A case report. ............................................................. 276
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Georges Azzi, MD .............................................. 277
The woman who coughed up bile ..................................................................................................... 277
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Shallini Sood, MBBS ........................................... 278
Rare case of Erythrocytosis in a case of Medullary sponge kidney .................................................. 278
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Syed Haider Imam, MBBS .................................. 279
SIADH vs renal salt wasting nephropathy - A Cisplatin induced dilemma!!! .................................... 279
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Carlos Martinez-Balzano, MD ............................ 280
Generalized epileptic condition caused by pregabalin ..................................................................... 280
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Balakumar Krishnarasa, MD .............................. 281
The Dangerous Duo: Post-surgical Thrombotic Thrombocytopenic Purpura and Heparin-Induced
Thrombocytopenia............................................................................................................................ 281
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Maryah Mansoor, MBBS ................................... 282
Reactive arthritis due to Clostridium difficile: an unfamiliar entity ................................................. 282
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Akshiv Malhotra, MBBS ..................................... 283
Anticoagulation without an antidote-Rivaroxaban induced fatal bleeding...................................... 283
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Jennifer Wang, DO............................................. 284
Miliary tuberculosis in a health care worker with negative pre-employment skin testing .............. 284
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Harkinder Khangura, MD ................................... 285
Seizures from the Heart .................................................................................................................... 285
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Ajay Dhakal, MBBS ............................................ 286
Multiple hepatic masses in a patient with Multiple Myeloma. ........................................................ 286
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Benjamin R Levin, MD ....................................... 287
Anaphylaxis induced Ventricular Fibrillation following Aspirin administration ............................... 287
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Nitipong Permpalung, MD ................................. 288
Don't let the tests mislead you! ........................................................................................................ 288
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Eliany Mejia Lopez, MD ..................................... 289
A Giant Left Ventricular Pseudoaneurysm: the Role of MRI............................................................. 289
NEW YORK POSTER FINALIST - CLINICAL VIGNETTE Oladunni Enilari, MD ......................................... 290
S1235R- a cystic fibrosis transmembrane conductance regulator gene mutation: an unusual cause
of recurrent acute pancreatitis ......................................................................................................... 290
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Megha Sawhney, MD ............................. 291
Multicentric Reticulohistiocytosis : An Unusual Cause of Polyarthritis mimicking Rheumatoid
Arthritis. ............................................................................................................................................ 291
IMPENDING PARADOXICAL EMBOLUS. ............................................................................................. 292
NORTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE James L Gentry III, MD ........................... 293
Death Delusions and Myoclonus in a Dialysis patient with multi-dermatomal Herpes Zoster: a
consequence of disease or treatment? ............................................................................................ 293
OHIO POSTER FINALIST - CLINICAL VIGNETTE Christian F Ghattas, MD, MSc ..................................... 294
Iatrogenic Tracheal Stenosis Mimicking Uncontrolled Asthma ........................................................ 294
OHIO POSTER FINALIST - CLINICAL VIGNETTE Muhammad K Riaz, MBBS .......................................... 295
Thrombophilia and hypofibrinolysis: treatable etiologies of Osteonecrosis of the knee................. 295
OHIO POSTER FINALIST - CLINICAL VIGNETTE Shruti Chaturvedi, MBBS ............................................ 296
Not the usual suspect: Sirolimus pulmonary toxicity presenting as fever and dyspnea in the
immune-compromised host.............................................................................................................. 296
OHIO POSTER FINALIST - CLINICAL VIGNETTE Tiffany N Latta, DO ..................................................... 297
Spondylodiscitis Due to Fastidious Gram-Negative Bacilli. Report of Two Cases and Review of
Literature. ......................................................................................................................................... 297
OHIO POSTER FINALIST - CLINICAL VIGNETTE Samer H Alsamman, MD ............................................ 298
Lung cavities in the young and healthy: Lemierre’s syndrome can still do it ................................... 298
OHIO POSTER FINALIST - CLINICAL VIGNETTE Phani C Kantamneni, MBBS ........................................ 299
Norwegian Scabies in a patient with psoriasis and renal transplantation: A deceiving presentation of
a rather rare condition! .................................................................................................................... 299
OHIO POSTER FINALIST - CLINICAL VIGNETTE Naresh Bumma, MD,MBBS......................................... 300
Celiac but not quite ........................................................................................................................... 300
OHIO POSTER FINALIST - CLINICAL VIGNETTE Rasha Al-Bawardy, MD ............................................... 301
Eosinophilia, pruritus and stroke: not all "HES" is HES .................................................................... 301
OHIO POSTER FINALIST - CLINICAL VIGNETTE Resham S Pawar, MBBS .............................................. 302
Cannabinoid Hyperemesis Syndrome: The new effect of an old drug! ............................................ 302
OHIO POSTER FINALIST - CLINICAL VIGNETTE Artan Kaso, MD........................................................... 303
Not Just another Case of back Pain! IVC Filter Strut Perforation. .................................................... 303
OHIO POSTER FINALIST - CLINICAL VIGNETTE Surbhi Sidana, MD ...................................................... 304
Axillary mass as the presenting symptom of poorly differentiated lung adenocarcinoma .............. 304
OHIO POSTER FINALIST - CLINICAL VIGNETTE Jason R Foreman, DO ................................................. 305
Nice Grab! ......................................................................................................................................... 305
OHIO POSTER FINALIST - CLINICAL VIGNETTE Nancy Nguyen, MD ..................................................... 306
Cardiac Involvement in Henoch Schonlein Purpura: A Case of Heart Failure and Arrhythmia ........ 306
OHIO POSTER FINALIST - CLINICAL VIGNETTE Preethi Gondi Kamma Venkatesh, MD ....................... 307
A Young Female with Hematemesis-Is this Vampirism .................................................................... 307
OHIO POSTER FINALIST - CLINICAL VIGNETTE Jennifer N Saultz, DO .................................................. 308
Loeffler’s Endocarditis secondary to idiopathic hypereosinophilic syndrome. ................................ 308
OHIO POSTER FINALIST - CLINICAL VIGNETTE Vivek Batra, MD .......................................................... 309
Surely You Are Joking Mr. S .............................................................................................................. 309
OHIO POSTER FINALIST - CLINICAL VIGNETTE Salem J Almaani, MD .................................................. 310
Weight Loss Supplements- A Current “Craze” .................................................................................. 310
US AIR FORCE POSTER FINALIST - CLINICAL VIGNETTE Matthew Thomas Koroscil ............................ 311
STREPTOCOCCUS CONSTELLATUS INFECTION .................................................................................. 311
OHIO POSTER FINALIST - CLINICAL VIGNETTE Bradley A Moore, MD ................................................. 312
Adult Onset Henoch-Schönlein Purpura: More Complicated than the Childhood Syndrome ......... 312
OKLAHOMA POSTER FINALIST - CLINICAL VIGNETTE David L Lazar, MD ............................................ 313
Abducens nerve palsy in a patient with AIDS and Non-Hodgkin lymphoma .................................... 313
OKLAHOMA POSTER FINALIST - CLINICAL VIGNETTE Deepna D Jaiswal, DO ...................................... 314
Surgery versus Snacking as Treatment for Insulinoma ..................................................................... 314
ONTARIO POSTER FINALIST - CLINICAL VIGNETTE Stephanid Dizon, MBChB ..................................... 315
Prolonged Proton Pump Inhibitor Use: A Precipitator of Hypomagnesemia ................................... 315
OREGON POSTER FINALIST - CLINICAL VIGNETTE Jeffrey A Youker, MD ............................................ 316
A Maddening Case of Confusion ....................................................................................................... 316
OREGON POSTER FINALIST - CLINICAL VIGNETTE Sarah Dawson, DO ................................................ 317
Georgia Home Boy the "Scoop" on a Targeted Treatment............................................................... 317
OREGON POSTER FINALIST - CLINICAL VIGNETTE Lidija Breznikar McGrath, MD............................... 318
Prion Disease in a Young Male .......................................................................................................... 318
First Author: Lidija Breznikar McGrath, MDAndrea Cedfeldt, MDRandy Woltjer, MD, PhD......... 318
OREGON POSTER FINALIST - CLINICAL VIGNETTE Rob Rope, MD ....................................................... 319
Rhabdomyolysis-Induced AKI with Mild CPK elevation and Delayed Hypercalcemia. ..................... 319
OREGON POSTER FINALIST - CLINICAL VIGNETTE Karen A Jenkins, DO .............................................. 320
A Coinciding Conundrum: “An Affliction of the Lymph Nodes” ....................................................... 320
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Sepehr Mesdaghinia, MD ........................... 321
Exertional syncope in a young woman with a rare hematologic disorder ....................................... 321
First Author: Sepehr Mesdaghinia, MDSecond Author: Eileen Hennrikus, MDThird Author: Maryam
Mohammadi, MD .............................................................................................................................. 321
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Leena Jalota, MBBS .................................... 322
Venous air embolism following femoral vein catheterization .......................................................... 322
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Daniel J Makowski, DO ............................... 323
Spontaneous Coronary Artery Dissection: A Rare but Deadly Cause of ACS in Younger Patients ... 323
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Robin Girdhar, MBBS.................................. 324
AFTER INFLUENZA VACCINE .............................................................................................................. 324
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Prabhat Singh, MD ..................................... 325
Bartonella endocarditis presenting as gastro-intestinal symptoms ................................................. 325
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Nonihal Singh, MBBS .................................. 326
An Under-Recognized And Under-Reported Cause Of Adrenal Insufficiency................................... 326
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jad G Sfeir, MD ........................................... 327
Hypocalcaemic Cardiomyopathy in the Setting of Pseudohypoparathyroidism .............................. 327
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Marlo D Bruno, DO ..................................... 328
Metal Matters: A Rare Presentation of Copper Deficiency after Gastric Bypass ............................. 328
PROPHYLAXIS .................................................................................................................................... 329
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Carlos D Davila, MD .................................... 330
Right Atrial Lipoma in a Patient with Complete Heart Block. ........................................................... 330
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Joseph Armenia, MD .................................. 331
The eye as a window to the central nervous system: visual loss as the presenting symptom of
neurosyphilis ..................................................................................................................................... 331
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Saveri Bhattacharya ................................... 332
Breast Cancer Metastasis to the Maxillary Sinus: A Case Report .................................................... 332
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Robert H Becker, MD ................................. 333
An Unusual Case of Cushing Syndrome Due to Prostate Small Cell Carcinoma ............................... 333
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Anjum Gaba, MBBS .................................... 334
Abatacept (Ornecia) associated disseminated Mycobacterium Avium Complex (MAC) Infection in a
non- HIV patient ................................................................................................................................ 334
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Sajid Farooq, MD ........................................ 335
Patients with COPD be cautioned about cats and dogs. A case report of Tracheobronchitis caused
by Pasteurella Multocida .................................................................................................................. 335
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Sivaranjani Penna, MBBS ........................... 336
A Tale of Right Ventricular Cardiac Myxoma .................................................................................... 336
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ravi Y Desai, MD ........................................ 337
A Rare Type of Body Cavity Lymphoma In A Patient With End Stage Alcoholic Liver Disease ......... 337
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ghazi Mirrani, MBBS .................................. 338
Exertional heat Stroke....................................................................................................................... 338
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Muhammad Tahseen, MD ........................ 339
Massive Gastrointestinal Bleeding from a Traumatic Gastric Injury ................................................ 339
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Anza Saleem, MD ....................................... 340
LATEX ALLERGY PRESENTING AS NEPHROTIC SYNDROME ............................................................... 340
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Alyson S Quigley, MD ................................. 341
An Unusual Case of Shortness of Breath .......................................................................................... 341
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Shakira J Grant, MBBS ................................ 342
Superior vena cava syndrome as an initial presentation of low grade follicular lymphoma ........... 342
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Seethal Tummala, MBBS ............................ 343
An uncommon cause of DVT: Thinking beyond the risk factors ....................................................... 343
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Wuqiang Fan .............................................. 344
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Vishal Goyal, MD ........................................ 345
Black Esophagus ................................................................................................................................ 345
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Julieta Gilson, MD ...................................... 346
Myocardial Infarction or Not? The Time is “Ticking” ........................................................................ 346
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Bhuvin Mukesh Buddhdev, MD ................. 347
Aortic Aneurysm Rupture Presenting As Acute Myocardial Infarction: A Rare Occurrence ............ 347
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Ronald Maag, MD....................................... 348
An Uncommon Complication of Heparin Induced Thrombocytopenia ............................................ 348
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Kameron S Ashker, MD .............................. 349
A Rare case of Community Acquired Pneumonia presenting with Pneumococcal Meningitis with
Pneumocephalus............................................................................................................................... 349
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Saveri Bhattacharya ................................... 350
Superwarfarin Poisoning: A case report and review of pathophysiology......................................... 350
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Jonathan I Gotfried, MD ............................. 351
Rising Use of Hydralazine: Beware of Side Effects ............................................................................ 351
PENNSYLVANIA POSTER FINALIST - CLINICAL VIGNETTE Kashmira Singh, MBBS ............................... 352
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Angel M Gonzalez-Cardona, MD ................... 353
Replace and keep Walking ................................................................................................................ 353
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Elvin Muniz-Ramirez ..................................... 354
ATYPICAL PRESENTATION OF MIGRAINE .......................................................................................... 354
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Marielly Sierra, MD, Patricia Fernandez, ...... 355
RITUXIMAB AS SINGLE AGENT. ......................................................................................................... 355
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Karely Cabrera, MD ....................................... 356
Small Bowel Obstruction in a Patient with Good Syndrome ............................................................ 356
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Luis Hernandez, MD ...................................... 357
An uncommon infectious disease mimicking a Cerebrovascular Accident ...................................... 357
PUERTO RICO POSTER FINALIST - CLINICAL VIGNETTE Sixto G. Giusti-Torres, MD............................. 358
Smoldering? “To exist in a suppressed state”................................................................................... 358
RHODE ISLAND POSTER FINALIST - CLINICAL VIGNETTE Daniel Chen, MD ......................................... 359
Cryptococcal Meningitis With Dissemination in an HIV Negative Patient ........................................ 359
SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Ben Kalivas, MD...................................... 360
Mitral regurgitation; a rare cause of alveolar hemorrhage. ............................................................. 360
SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Molly C McVey, MD................................ 361
Salmonella Induced Reactive Arthritis .............................................................................................. 361
SOUTH CAROLINA POSTER FINALIST - CLINICAL VIGNETTE Anne D Drabkin Schade, MD .................. 362
Just stick to beer ............................................................................................................................... 362
SOUTH DAKOTA POSTER FINALIST - CLINICAL VIGNETTE Pooja Aggarwal, MD .................................. 363
Tracheo-bronchitis Associated With Ulcerative Colitis ..................................................................... 363
SOUTH DAKOTA POSTER FINALIST - CLINICAL VIGNETTE John K Wachira, MD .................................. 364
Coronary to Pulmonary Artery Fistulas in Bacterial Endocarditis: A Rare Incidental Finding .......... 364
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Stanley T Pace, MD ........................................... 365
Psoas Abscess as the Initial Presentation of Crohn's Disease: An Unusual Case .............................. 365
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Sister Mary Gretchen Hoffman, MD ................. 366
A Common Problem with an Unlikely Suspect ................................................................................. 366
TENNESSEE POSTER FINALIST - CLINICAL VIGNETTE Scott Duncan, MD ............................................. 367
A 41 year old female with a lung mass and multiple lung nodules. ................................................. 367
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Sarmad Said, MD ....................................................... 368
Fulminant Course of Moyamoya Disease Presenting as a Corpus Callosum Infarct in a Hispanic Male
.......................................................................................................................................................... 368
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Sergio A Torres, MD .................................................. 369
A Case of Diabetic Ketoacidosis with Euglycemia ............................................................................. 369
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Adrienne D Scott, DO ................................................ 370
Autoimmune Encephalopathy: A Case of Limbic Encephalitis.......................................................... 370
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Giovanni E Davogustto, MD ...................................... 371
Acute abdomen: unusual initial presentation of systemic lupus erythematous .............................. 371
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Norys Alexandra Castro Pena, MD ............................ 372
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Chad Cooper, MD ...................................................... 373
Nephrotic Proteinuria in a Chronic Subcutaneous (“Skin Popping”) Heroin Abuser. ....................... 373
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Benjamin Wilson, MD ............................................... 374
Purpura Fulminans – A Rare Manifestation of West Nile Virus Infection......................................... 374
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Lavanya Viswanathan, M.D. .................................. 375
Severe Iron Deficiency Anemia With Thrombocytopenia................................................................. 375
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Habeeb M Salameh, MBBS ....................................... 376
Duodenal Perforation, Vertebral Body Perforation and Abutment of Abdominal Aorta after Cook
Celect™ Vena Caval Filter. Is Endovascular Retrieval Possible?........................................................ 376
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Thomas Delmas, MD ................................................. 377
Thalidomide Nerve Toxicity – Not Just Sensory Anymore ................................................................ 377
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Thanh Tran, MD ........................................................ 378
Healthy 25 year old Male with Multiple Pulmonary Nodules, Diffuse Lymphadenopathy and
Splenomegaly .................................................................................................................................... 378
TEXAS POSTER FINALIST - CLINICAL VIGNETTE David A Rubio, MD .................................................... 379
A Case of Cardiobacterium Hominis Prosthetic Valve Endocarditis ................................................. 379
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Jorge Machicado-Rivero, MD .................................... 380
Gastrointestinal bleeding: don't overlook the pancreas .................................................................. 380
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Kongkiat Chaikriangkrai, MD ..................................... 381
Single Coronary Artery With Ischemia .............................................................................................. 381
TEXAS POSTER FINALIST - CLINICAL VIGNETTE Elan Gada, MD........................................................... 382
Bowel-associated dermatosis-arthritis syndrome in a non-surgical patient. ................................... 382
TEXAS POSTER FINALIST - CLINICAL VIGNETTE CAPT Anthony P Sidari .............................................. 383
Ockham’s Razor? Not quite: Two rare pulmonary diagnoses in a 25-year-old active duty smoker. 383
US ARMY POSTER FINALIST - CLINICAL VIGNETTE LT Geoffrey J Cole, MD ........................................... 384
Crazy, Maybe Not: N-Methyl-D-Aspartate Receptor Antibody Encephalitis .................................... 384
Spicing Up the Differential for Cyclical Vomiting .............................................................................. 385
US NAVY POSTER FINALIST - CLINICAL VIGNETTE LT Hillary A. Chace, MC USN ................................. 386
Spontaneous coronary artery dissection (SCAD) .............................................................................. 386
VERMONT POSTER FINALIST - CLINICAL VIGNETTE Samreen Raza, MD ............................................. 387
When biopsy prevails and therapy fails – a fascinating case of Rheumatoid Meningitis (necrotizing
granulomatous meningitis) while on TNF blocking therapy ............................................................. 387
VERMONT POSTER FINALIST - CLINICAL VIGNETTE Deva Sharma, MD............................................... 388
An Unusual Case of Typical Angina ................................................................................................... 388
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Seth T Parsons, MD .............................................. 389
THE BLOOD STOPS HERE ................................................................................................................... 389
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Kenneth H Surkin, MD .......................................... 390
AUTOIMMUNE POLYGLANDULAR SYNDROME TYPE III .................................................................... 390
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Leigh S Goldstein, MD .......................................... 391
Bullous Pemphigoid and Coagulopathy ............................................................................................ 391
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Craig S Toxey, MD................................................. 392
Cerebral Venous Sinus Thrombosis Secondary to NuvaRing Use ..................................................... 392
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Thomas Bradley Murray, MD ............................... 393
Do You Believe in GAD? .................................................................................................................... 393
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Ivonne Marie Pena, MD ....................................... 394
A Unique Case of Intractable Vomiting: Cannabinoid Hyperemesis Syndrome ............................... 394
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Matthew Donald Bernens, MD ............................ 395
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Stephanie Ann Grotzke, MD................................. 396
To be or not to be Dengue? Rash and thrombocytopenia in a returning traveler. .......................... 396
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Sasha Kareshma Mangray, MD ............................ 397
An interesting case of binocular diplopia ......................................................................................... 397
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Bonny Lauren Moore, MD .................................... 398
Ocular Syphilis: Staring Straight at You ............................................................................................. 398
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Ryan K Fawley, MD ............................................... 399
PSEUDOANEURYSM .......................................................................................................................... 399
UTAH POSTER FINALIST - CLINICAL VIGNETTE Craig D Robison, MD .................................................. 400
Acromegaly: Missing the Forest through Very Large Trees .............................................................. 400
VERMONT POSTER FINALIST - CLINICAL VIGNETTE Patrick K Hohl, DO .............................................. 401
Lyme Carditis in an Elderly Man with Native Conduction Disease ................................................... 401
VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Jared N Silver, MD ................................................ 402
An Uncommon Variable of Common Variable Immunodeficiency ................................................... 402
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Maria Theresa S Kurtz, DO ................................... 403
PSEUDOMEMBRANOUS COLITIS ON COLONOSCOPY ....................................................................... 403
WASHINGTON POSTER FINALIST - CLINICAL VIGNETTE Aaron T Fang, MD ........................................ 404
A Rarely Confirmed Diagnosis with a Classic Presentation: Primary Systemic Amyloidosis (AL) with
Tissue-Proven Cardiac Involvement.................................................................................................. 404
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT Patrick R Smith, MC USA ................................ 405
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Samir S Majmudar, DO ......................................... 406
.......................................................................................................................................................... 406
US ARMY POSTER FINALIST - CLINICAL VIGNETTE Jack B Ellis, DO...................................................... 407
HYPOGAMMAGLOBULINEMIA IN A NEUTROPENIC HOST ................................................................ 407
US ARMY POSTER FINALIST - CLINICAL VIGNETTE CPT David E. Anderson, MD .................................. 408
DILEMMA .......................................................................................................................................... 408
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Naga Praneeth Raja, MD ............................ 409
Almost Dead...Again? ........................................................................................................................ 409
A case of recurrent anaphylaxis ........................................................................................................ 409
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Sherri L Rauenzahn, MD ............................. 410
Acute myeloid leukemia (AML) mimicking acute appendicitis ......................................................... 410
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Andra L Fee-Mulhearn, DO ........................ 411
Do Scars Grow? A unique dermatological presentation of a systemic disease ................................ 411
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Tilahun W Belay, MD .................................. 412
Lisinopril Overdose Requiring Hemodialysis- a case report ............................................................. 412
WEST VIRGINIA POSTER FINALIST - CLINICAL VIGNETTE Brandon Rose, DO ...................................... 413
A “Bite” Confused ............................................................................................................................. 413
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Zainab Ajoke Ashir ........................................... 414
What's a Hunter Without His Vision? ............................................................................................... 414
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Lyndsey N Runaas, MD..................................... 415
An Unusual Case of Dysphagia: The Importance of Physical Exam .................................................. 415
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Alice Jacob, MD ................................................ 416
A curious case of weakness............................................................................................................... 416
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Jonathan S. Kurman, MD.................................. 417
Still a Challenging Diagnosis .............................................................................................................. 417
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Emily Fisher, MD .............................................. 418
What's that pustule?! Bringing Mass Spectrometry to the Bedside................................................. 418
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Natalia Usoltseva, MD ...................................... 419
Spinal Subdural Empyema - a rare complication of Decubitus Ulcer with Superimposed Epidural
Hematoma leading to Spinal Cord Compression .............................................................................. 419
WISCONSIN POSTER FINALIST - CLINICAL VIGNETTE Ben Ravaee, MD ............................................... 420
DOUBLY UNCOMMON ...................................................................................................................... 420
Podium Presentations
West Nile Neuroinvasive disease mimicking Amyotrophic lateral Sclerosis
First Author: ANKIT MANGLA, MD Second Author: ALANA NEVARES, MD
INTRODUCTION: West Nile (WN) Virus infection was first seen in Americas in 1999. This year alone,
5,207 cases have been reported to CDC till November, a number which is highest since the epidemic of
2003. We present a case of 56-year old man presenting with upper and lower motor neuron lesions and
aseptic meningitis, an atypical presentation, who was serologically diagnosed as West Nile
Neuroinvasive disease (WNND).
CASE DESCRIPTION: 56 year old Hispanic man presented in late July with diffuse myalgia and generalized
body weakness for 3-weeks, non productive cough for 1-week and non bloody, non mucoid diarrhea for
3-days. Vital signs were all normal. Neurological exam showed grade 3 deep tendon reflexes in upper
and lower limbs, decreased tone and widespread fasciculation in upper and lower extremities along with
power of 3/5 in shoulder and hip with mild wasting and 4/5 power in all other muscle groups The gait
was wide based. Laboratory analysis was significant for leucocytosis (14.4X109/L) with left shift and mild
hyponatremia (133mEq/L). Cerebropspinal fluid (CSF) analysis showed aseptic meningitis with WBC
count of 22/uL (78% lymphocytes and 4% polymorphs), elevated proteins (0.86gm/L) and normal
glucose (53mg/dL). Creatinine Kinase was elevated (184U/L). CT scan of spine and head showed mild
chronic degenerative changes. MRI Brain and spinal cord were not done in view of his occupation as a
welder and raised suspicion of orbital splinters. Electromyography showed chronic involvement of
motor units, producing large amplitude and wide duration motor unit potentials in some muscles. CSF
was positive for IgG and IgM antibodies against WN virus. The patient received supportive therapy and
continues to receive outpatient physical therapy with slow partial recovery.
DISCUSSION: Summer and fall are most notorious for spread of WN virus which is the peak season for
its carrier mosquitoes. Most common neuromuscular presentation in WN disease is anterior horn cell
involvement flaccid paralysis and few cases have been reported with transverse myelitis like syndrome
causing upper motor neuron lesion. Our patient presented with a mix of upper and lower motor neuron
lesions (exaggerated reflexes and fasciculations with wasting respectively), which is a characteristic for
Amytrophic lateral sclerosis and very atypical for WNND. However, since he came during summer (end
of July) and belonged to an endemic area (Illinois State) we were compelled to think of WN Disease.
Serologically positive CSF, the standard criteria for diagnosing WNND, clinched the diagnosis for us and
reinstated the fact that any patient with neuromuscular involvement presenting during peak season
belongs to an endemic region should be considered for WN disease, as the prognosis is significantly
better with more chances of complete neurologic recovery.
sulaiman, MD
Is this a true STEMI?
First Author: Samian sulaiman, MD
Learning objectives:
To recognize that an aVR ST elevation is a valuable indicator of the acute LMCA obstruction or
proximal LAD obstruction
To recognize classic T waves of Wellen’s syndrome which reliably suggest a high-grade stenosis
of the proximal left anterior descending (LAD) artery.
To recognize STEMI in the presence of incomplete LBBB.
Case Presentation: A 63 year/old male presented with sudden onset, sharp, non-radiating, and
retrosternal chest pain that started one hour prior to arrival. He also was complaining of mild shortness
of breath, sweating and palpitation. He reported having intermittent chest pain over the last week, but
this episode was more severe and constant. Aspirin was given En route to the hospital. His Past medical
history was significant for hypertension, hyperlipidemia, sleep apnea and restless leg syndrome. His
medications included aspirin, simvastatin, enalapril and metoprolol. On physical examination, his BP
was 214/126 mm Hg; the rest of physical examination was unremarkable. EKG showed ST elevation in
leads (aVR, V1, V2) with incomplete LBBB. Chest X-ray showed a wide mediastinum. Initial labs were
unremarkable. Due to the presence of incomplete LBBB and discordant ST elevation in addition to
absence of an old EKG, ST elevation was considered nonspecific. First two sets of cardiac markers were
negative. CT angiography of the chest did not show aortic dissection or dilatation. His chest pain was
relieved temporarily with sublingual nitroglycerin. 2 doses of IV metoprolol were given and Nitroglycerin
drip was started. After ruling out aortic dissection a 300 mg of Plavix was given. He was admitted to the
CICU for close monitoring.
Two days later, a nuclear medicine stress test showed a large fixed perfusion defect in the anterior,
septal and inferior walls. Patient had recurrent chest pain and an EKG at that time showed deep,
inverted T waves in the precordial leads (V2-V3). On the 4th day, the patient the patient underwent
Coronary angiography, which showed 99% ostial occlusion of the LAD. Due to the proximity of the lesion
to LMCA, balloon was not inflated in order to avoid LMCA damage. Later on, the patient had off-Pump
CABG with LIMA attached to LAD. Looking retrospectively, the ST elevation in leads aVR, V1, and V2 on
admission was a true STEMI, and the incomplete LBBB was over-diagnosed. 2 sets of cardiac markers
were drawn within the first 2 hours of presentation which can be falsely normal.
Discussion: An aVR lead gives significant information about the right outflow tract and the basal part of
septum. The latter is supplied by the first septal branch of LAD. The aVR ST elevation is a valuable
indicator of the acute LMCA obstruction or proximal LAD obstruction involving the first septal branch.
The classic Wellen’s T-waves are described as either deeply inverted (> 2 mm) or biphasic T waves in V2V3. Discovering Wellens' syndrome is imperative as 75% of patients will develop acute anterior wall
myocardial infarctions (MIs) within one week unless intervention is undertaken urgently. To diagnose
STEMI in patients with incomplete LBBB, ST elevation should be in the same direction (concordant) as
the QRS.
Eunice Y Chuang, MD
Somatostatinoma presenting as uncontrolled diabetes, hypercalcaemia and
weight loss
First Author: Eunice Y Chuang, MD Other: Indumathy Varadarajan MD
Introduction: Somatostatinomas are rare neuroendocrine tumors with an incidence of 1 in 40 million.
They originate from the somatostatin-producing delta cells of the pancreas and the endocrine cells of
the digestive tract. The most common symptoms are abdominal pain and weight loss. The classic triad of
somatostinoma consists of diabetes, cholelithiasis and diarrhea, but very few patients present with all
these symptoms.
Case Presentation: 51 year old male with history of diabetes, obesity and a current smoker was found to
have serum calcium of 12.8 mg/dl and HbA1C of 9.3% in a routine physical exam. Patient was otherwise
asymptomatic except for an unintentional weight loss of 30 pounds in the last 2 years . Hypercalcemia
was first noticed a year ago with a calcium of 10.4 mg/dL, with a steady increase and a normal PTH at all
instances of follow up. Diabetes had been diagnosed 2 years ago when he presented with weight loss,
polydipsia, polyuria and a HbA1C of 11.5%. He responded to Metformin with an improvement of HbA1C
to 6.9% in one year. He was hence started on Insulin for the diabetes that now seemed difficult to
control. Furthur investigations revealed an Albumin 4.9 g/dL, BUN 14 mg/dL, Creatinine 0.7 mg/dL,
Phosphorus 2.5 mg/dL, VIT D1,25-OH 80 pg/mL, PTH-RP 84 pg/mL (14-27). Serum protein
electrophoresis was normal. Given the smoking history and hypercalcaemia a CT Chest was ordered to
rule out lung malignancy, that incidentally revealed an 8.2 x 8.6 cm enhancing mass in the pancreas and
multiple liver metastases. CT abdomen confirmed these findings but also showed thrombosis of the
splenic vein, compression of the superior mesenteric vein and presence of peripancreatic lymph nodes.
Biopsy of the liver revealed a well differentiated metastatic low-grade neuroendocrine tumor. Tumor
cells were positive for somatostatin and negative for insulin and glucagon. Octreotide scan confirmed
abnormal uptake in the pancreatic mass and hepatic lesions. CT head was negative for metastasis.
Patient was diagnosed with metastatic pancreatic somatostatinoma and was started on octreotide.
Zoledronic acid was inintiated for the worsening serum calcium. Despite therapy patient complained of
abdominal distension with bloating, shortness of breath and weight gain. Repeat CT scans showed
progression of disease; therefore he was initiated on temozolomide instead of the octreotide.
Discussion: Somatostatinoma accounts for less than 1% of gastroenteropancreatic endocrine tumors.
Functional somatostatinoma occur more often in the pancreatic tumors. Our patient presented with
uncontrolled diabetes as a consequence of the inhibitory effect of somatostatin on insulin secretion.
Hypercalcaemia due to PTH-rP hypersecreation is a rare feature of endocrine pancreatic tumor which
can complicate its clinical course. The first line therapy for symptomatic and unresectable
somatostatinoma is octreotide. However, prognosis in metastatic disease is poor,despite therapy and
has a 56% five year survival.
Patel, DO
A thrombus in the Left Anterior Descending Artery after the use of multiple
alternative medicines
Brijesh Patel DO, Timothy Larsen DO, Sachin Kumar Amruthlal Jain MD, Patrick Alexander MD, Shukri
David MD
Introduction: Certain forms of alternative medicine have been in practice for many centuries. By
definition, alternative medicine is something that differs from or is outside the scope of conventional
medical practice. In an effort to seek relief many patients turn to alternative therapies. Patients who
use these substances generally assume they are safe as these substances are purchased over the
counter, contain “natural” ingredients which are neither tested nor approved by the US Food and Drug
Administration. Thus, Patients and physicians are generally not aware of the potential risks that these
remedies may carry.
Case Report: A 34 year old female presented to the emergency room complaining of sudden onset
severe stabbing substernal chest pain that radiated to her back. The pain started while walking. The
initial episode lasted 20 minutes and resolved with rest. The pain returned with minimal exertion. She
was moderately short of breath but denied nausea, light-headedness, palpitations, or diaphoresis. Her
medical history was significant for gluten intolerance and exercise induced asthma. There was no family
history of heart disease or sudden cardiac death. She denied taking prescription medications, she had,
however, been taking multiple alternative medications in hopes of curing her gluten sensitivity. These
included a diet pill, Lachesis Mutus 12X (pit viper venom), Bella Donna 12X, Crotalus Horridus 12X (rattle
snake venom), lyssin (saliva of rabid dog), pyrogenium 12X (made from beef left standing in water for 3
weeks), and Tarantula Cubensis 12X (dehydrated, ground tarantula ). Her Vital signs were normal.
Physical exam was unremarkable. Initial troponin was 0.02; repeats six hours apart were 0.31 and 0.37;
other blood tests were normal. There were no ischemic changes on serial EKGs. She was referred for
cardiac catheterization which identified an acute thrombus in the mi-left anterior descending artery The
patient’s Right Coronary Artery was patent. Thrombectomy was performed and a stent was placed.
After the procedure she was free of pain. Other workup for hypercoagulation state was negative.
Discussion: This case illustrates the potentials risks associated with ingesting unknown and untested
medications. These substances have not been studied in order to determine safety and efficacy. The
Lachesis Mutus and Crotalus Horridus venoms are believed to cause damage to the vessel intima and
promote platelet aggregation. Even though most substances are significantly diluted prior to
administration, several are active at very low concentrations. The Naranjo probability scale identifies our
patient's myocardial infarction as a probable adverse drug reaction.
Kulairi, MBChB
Von Willebrand disease and Schwannomatosis----Role of psudogene!
First Author: Zain I Kulairi, MBChB Kavyashri Kodlipet Jagadeesh, MD Reema George P Manickam, MD
Sarwan Kumar, MD Tariq Mubarak, MD Department of medicine, Wayne State University/ Crittenton
Hospital Medical Center. Sagar Mallikethi Lepakshi Reddy, MD
Introduction: Von Willebrand disease is a common hereditary bleeding disorder. Its primary gene defect
is at short arm of chromosome 12, but is complicated by the presence of a partial unprocessed
pseudogene on chromosome bands 22q11.22 and 22q11.23. Schwannomatosis is a rare hereditary
condition usually caused by germ line mutations and deletions of SMARCB1/INI1 in chromosome band
We are presenting a unique case suggesting that pseudogene mutation was responsible for the
development of Von Willebrand disease in a patient having Schwannomatosis.
Case Presentation: A 29-year-old patient with a history of diffuse schwannomatosis caused by mutation
in the SMARCB1 gene, presented with bleeding. The platelet function activity measurements were
greater than 300 seconds for both collagen/epinephrine and collagen/ADP. Factor VIII activity was low
at 57 and 37, and the Von Willebrand factor activity and antigen levels were 24 and 33 respectively.
Patient was diagnosed with Von Willebrand disease based on these abnormal platelet function tests.
The patient’s Von Willebrand disease responded appropriately to a therapeutic trial of desmopressin.
Discussion: Pseudogenes are also referred to as potogenes that are defined as DNA sequences having an
ability to become a functional gene. Many studies have reported the ability of the pseudogene to
render an adjacent functional gene inactive. Our patient was proven to have a mutation of SMARCB1
gene at chromosome band 22q11.2 that is located near the pseudogene associated with Von Willebrand
disease. We hypothesize the possibility that the pseudogene mutation was responsible for the
pathogenesis of Von Willebrand disease. If further studies support this possible genetic linkage, days are
not far when we start including pseudogenes as an integral part of our functional DNA and not just
considering them as potogenes.
Baharith, MD
Postpartum reversible vasoconstriction syndrome
First Author: Harith Baharith, MD, Co-Author: Amy Zarrin, MD, New York Methodist Hospital, Brooklyn,
New York
Introduction: Postpartum cerebral vasoconstriction is one of the rare, reversible cerebral
vasoconstriction syndromes (RCVS). We report a patient with headache and focal neurological deficits
that occurred one week after delivery, with segmental narrowing of cerebral arteries on angiography.
Case Report: A 35 year old woman (gravida 10, para 11) presented with throbbing headache beginning
five days after Caesarean section. Ten days after delivery, she developed decreased right sided
sensation, tingling and weakness, with right facial droop, tongue heaviness and difficulty speaking. The
patient denied past medical problems, but had a long history of chewing khat (methcathinone, a methyl
derivative of cathinone, an ephedrine amphetamine-like stimulant) and a 5-year smoking history
(tobacco). During the Caesarean section, she received 4 units of packed red blood cells. Physical
examination showed right lower facial droop, and diminished power (2/5) of the right arm and (3/5) leg.
Her brain computerized tomography (CT) scan showed acute left middle cerebral artery infarction. On
day 2, magnetic resonance angiography (MRA) showed vasoconstriction of the middle and anterior
cerebral arteries. On day 3, head CT angiography showed diffuse vasoconstriction of medium and small
vessels. The blood count, chemistry panel, sedimentation rate, C-reactive protein, autoimmune studies,
hypercoaguability testing, electroencephalogram and echocardiogram were all unremarkable. Hepatitis
B, hepatitis C and syphilis antibodies were negative. She received verapamil for relieving
vasoconstriction and levetiracetam for seizure prophylaxis. Head MRA on day 6 showed significant
resolution of her vasoconstriction. Follow up revealed clinical resolution.
Discussion: Strokes in pregnant and postpartum women are generally caused by: cerebral venous
thrombosis, preeclampsia/eclampsia or RCVS. Postpartum strokes incidence ranges from 4.3-210 per
100,000 deliveries with unknown RCVS incidence. Most strokes occur in the third trimester and
postpartum period, when physiological changes affect cerebrovascular tone. Postpartum cerebral
vasoconstriction is often under-diagnosed, but recently disease recognition is increasing. This disorder
has various precipitating factors such as vasoactive substances, blood transfusion or can occur
spontaneously postpartum. The disorder may last for a short period of time or may become persistent
with poor outcome if severe vasoconstriction leads to brain ischemia or hemorrhage. The clinical
presentation includes thunderclap headache, focal neurological deficits and seizures which are usually
reversible within a 3 month period. Angiography usually shows segmental narrowing of cerebral arteries
that resolves completely or near-completely within 3 months. Our patient developed initial symptoms
within the first week after delivery and recovered completely. She had a history of two possible
precipitating factors: chewing khat and blood transfusion. Her repeat head MRA showed significant
resolution of cerebral vasoconstriction 2 weeks after her initial symptomatic presentation. Treatment
consists of eliminating any precipitating agents, verapamil and levetiracetam. Most patients recover
completely with few having residual deficits.
Wang, DO
Acute confusional migraine or stroke?
Jennifer Wang DO, Nadia Irshad MBBS, Anil Kapoor MD
Introduction: Complex migraine is a headache lasting 4-72 hours, sometimes associated with difficulty
speaking, weakness, and loss of vision. In the 2nd century, Aretaeus described recurrent headache with
spasms, facial distortions, eye pain, vertigo, sweating, nausea, vomiting, collapse, anxiety, photophobia
and phonophobia. Pathophysiology is believed to include neurovascular phenomena involving blood
vessel spasms followed by dilation, resulting in stroke-like symptoms and headaches.
Case: An 85-year-old Caucasian female with a past medical history of severe migraines, hypertension,
and hypercholesterolemia presented with altered mental status, hypertension and severe headache.
The day before admission, patient independently performed all activities of daily living. Prior to
admission, she fell and hit her forehead. The patient was disoriented, hallucinating, had worsening
confusion, but no urine or fecal incontinence.
The patient had no slurred speech or facial droop, but babbled incoherently despite fluency in English
and Italian at baseline. Vital signs were normal except BP 210/103. Review of systems was positive for
nausea and vomiting. Physical exam revealed a sedated but uncomfortable elderly female with a
forehead scar. On further questioning, we found that in the past, she had episodes of severe migraines
without auras occurring years apart, and were characterized by severe confusion, disorientation,
hallucinations, vomiting, and inability to speak for a few hours.
CT head revealed chronic small vessel disease and no acute infarctions, hemorrhages, or masses. MRI
head showed atherosclerotic disease and chronic small vessel ischemia. 2D ECHO showed concentric left
ventricular hypertrophy, and normal systolic function and ejection fraction. Laboratory findings were
within normal limits. In the following days, patient’s vital signs remained stable and her mental status
showed improvement to baseline. Based on these findings a diagnosis of encephalopathy secondary to
severe complex migraine was made. The patient was not started on any triptans or ergotamines as her
headache and neurological symptoms completely resolved and episodes were years apart.
Discussion: Complex migraines are often misdiagnosed as strokes. According to the American Academy
of Neurology, 18% of women, and 6% of men suffer from migraines. CT, MRI, and laboratory exams are
usually normal. Since complex migraines are the most debilitating form of headaches, it should be
considered as a differential when headaches are associated with: unilateral, pulsatile, moderate to
severe pain, nausea, vomiting, photophobia, phonophobia, or eye pain. 5 or more episodes are required
to differentiate it from tension headaches. Migraine triggers include alcohol, and physiological changes
such as hormones, stress, fatigue, and hunger. In conclusion, the presentation of complex migraines
often includes symptoms seen in other neurological conditions. Therefore, a detailed history is essential
to making the correct diagnosis and to differentiate from other diseases with similar presentations.
Mohammed A Farooqui, MBBS
First Author: Mohammed A Farooqui, MBBS W HARRIS; H BRANTLEY; J BROOKS
Stress-induced cardiomyopathy or “Broken Heart Syndrome” is a rare, but increasingly reported
syndrome with prevalence of about 1.2 percent. It is characterized by transient systolic dysfunction of
the apical and/or mid segments of the left ventricle that mimics myocardial infarction (MI), but in the
absence of obstructive coronary artery disease. The onset of stress-induced cardiomyopathy is
frequently, but not always, triggered by an acute medical illness or by intense emotional or physical
stress. Association between ECT and troponin elevation has been well known, but only few case studies
have illustrated its association with stress induced cardiomyopathy.
We report a case of 63 year old female with no prior cardiac history and normal left ventricular function
admitted to Psychiatry unit to undergo ECT for refractory depression. After the second trial of ECT, she
developed substernal chest pain, dyspnea and hypoxemia. EKG revealed dynamic changes with diffuse T
wave inversions. There was mild troponin I elevation of 0.29 ng/mL and B-type natriuretic peptide of
1663 pg/mL. CT chest ruled out pulmonary emboli, but interestingly showed reflux of intravascular
contrast within the inferior vena cava and central hepatic veins reflecting passive hepatic congestion.
ECHO and nuclear myocardial perfusion imaging revealed a LVEF of 20% and mild stress induced
ischemia respectively, while left heart catheterization and coronary angiography revealed mild coronary
artery disease with apical ballooning and apical hypokinesis. Takotsubo cardiomyopathy was diagnosed
based on typical ventriculogram findings. She was treated with appropriate medical therapy and
improved symptomatically with follow up ECHO three months post discharge.
This case report highlights a previously undocumented complication of ECT, and adds to the growing list
of stressors responsible for cases of Takotsubo cardiomyopathy. Despite its infrequent occurrence,
physicians should be aware that stress induced cardiomyopathy can be a potential contributor to heart
failure for patients undergoing ECT. Also the prognosis of Takotsubo cardiomyopathy is favorable, and
recovery is generally complete with early recognition of the syndrome and proper supportive treatment.
Ewelukwa, MBBS
A Case of Xanthogranulomatous Cholecystitis Mimicking Gallbladder Cancer
First Author: Oforbuike Ewelukwa, MBBS Second author: Omair Ali, MD Third author: Salma Akram, MD
Introduction Elderly patients presenting with obstructive jaundice are often thought to have underlying
hepatobiliary malignancy. We present an interesting case where no malignancy was identified, rather
symptoms, biochemical derangements and radiological findings were due to xanthogranulomatous
cholecystitis (XGC).
Case A 74 year old white female presented with jaundice. She denied any history of gallbladder (GB)
disease, smoking or alcohol intake. She denied symptoms of fever, nausea, vomiting, abdominal pain,
weight loss or changes in bowel movement, color or consistency. Examination revealed generalized
icterus with excoriation marks. Abdomen was non-distended with BS+, diffuse tenderness especially at
the right upper quadrant with positive Murphy's sign. Labs were normal except LFT that showed AST 93,
ALT 74, total bilirubin 7.0, direct bilirubin 4.1, indirect bilirubin 2.9 and ALP 1050. Abdominal ultrasound
showed an irregularly thickened GB with mild dilatation of the extra hepatic bile duct. CT abdomen and
magnetic resonance cholangiopancreatography revealed a markedly thickened, contracted GB with
submucosal hypoattenuated nodules. Endoscopic retrograde cholangiopancreatography revealed
opacification of the biliary tree and cystic duct with no common bile duct (CBD) dilatation, mucosal
irregularity, filling defect or stricture. Above findings were suspicious for a primary GB carcinoma.
Laparoscopic cholecystectomy was converted to an open cholecystectomy with liver resection due to
extensive adhesions. Surgical pathology revealed subacute cholecystitis with xanthomatous
inflammation with no evidence of malignancy and patient recovered fully post-op.
Discussion XGC is a rare chronic granulomatous inflammation of the GB first described by Christensen et
al in 1970 as "fibroxanthogranulomatous inflammation'' and later in 1976 as XGC by McCoy et al. It is
predominantly seen in the Japanese or South Asian population with age of presentation between 44 and
63 years. Its clinical, radiologic and operative features can mimic a hepatobiliary malignancy. Laboratory
tests often show non-specific derangements. Imaging may show GB wall thickening, stones, dilatation of
CBD and/or intramural hypoechoic nodules. XGC's inflammatory foci may extend to adjacent structures
which on CT imaging resemble an encroaching GB malignancy. A clue to radiological differentiation of
XGC from GB malignancy is the CT finding of intramural hypodense band in the GB in patients with XGC
though this specific finding was not found in this patient. However, diagnosis is mainly pathological.
Macroscopically, the GB is thickened with nodules formed of inflammatory foci. Histology will reveal
several distinct inflammatory cells, fibroblasts and lipid-laden macrophages. Complications include
fistulae from GB to the skin or duodenum and a high rate of post-operative infection. Surgery is the
preferred treatment option and up to 80% of laparoscopic procedures are converted to open surgery
mainly due to extensive adhesions, dense fibrosis and concerns of possible malignancy. Post-op
prognosis is usually very good and patients tend to make full recovery.
Machicado-Rivero, MD
Acute disseminated encephalomyelitis: A rare complication of influenza
First Author: Jorge D Machicado, MD Second Author: Giovanni Davogustto, MD
Introduction: Acute disseminated encephalomyelitis (ADEM) represents an immune mediated disorder
of the CNS characterized by brain and spinal cord demyelination. Post-vaccination ADEM accounts for
less than 5% of all ADEM cases. We present a rare case of post influenza vaccination ADEM, emphasizing
the paramount importance of recognizing recent vaccination exposures.
Case Presentation: An 83-year-old woman presented with 1 day of altered consciousness, weakness
and fevers. Her medical history included hypertension, diabetes type 2 and ischemic stroke. During the
previous 2 days she had experienced retro-orbital pain. On admission, she was found to be obtunded,
febrile (103.5°F), tachycardic and tachypneic. On neurological examination she had quadreparesis, brisk
reflexes, bilateral extensor plantar response and perioral fasciculation. The rest of the physical exam
was normal. CT of the head was unremarkable. CSF analysis revealed lymphomonocytic pleocytosis (44
cells/µL) and elevated proteins. Empiric antibiotics were started for presumptive meningoencephalitis.
Thorough evaluation revealed history of recent influenza influenza vaccination 5 days prior to
admission. MRI of the brain and spine showed extensive T2 hypersensitivity in the periventricular white
matter, bilateral thalami, midbrain, brainstem, and medulla oblongata. Her mental status declined,
along with worsening focal findings and respiratory failure, requiring mechanical ventilation.
Intravenous methylprednisolone was given for 5 days for suspected ADEM with no clinical improvement
and worsening radiologic abnormalities. Further tests for infectious diseases including CSF bacterial and
fungal cultures; CSF PCR for HSV, VZV, HHV-6, enterovirus, JC and BK viruses; serology for West Nile, St.
Louis, Western equine, Eastern equine and California encephalitis; serology for Lyme disease;
Cryptococcal and Histoplasma antigens; VDRL; HIV viral load and Quantiferon-TB test, were all negative.
CSF anti-NMDA receptor antibody and 14-3-3 protein were negative. CSF flow cytometry was
inconsistent with lymphoma. She had no improvement after completion of antibiotics. Then, 5 sessions
of plasma exchange were performed with dramatic clinical and radiologic improvement. She was
subsequently discharged to a rehab facility with no neurological deficit.
Discussion: Although rare, it should be recognized that certain vaccines may trigger serious neurological
immunophenomena such as Guillain-Barre syndrome, seizures, and ADEM. Post-vaccination ADEM
occurs in 0.1-0.2 per 100,000 vaccinated individuals. A recent literature review identified 15 published
reports of post influenza vaccination ADEM since 1982. Symptoms usually appear between 1-21 days,
and include altered consciousness with multifocal neurological findings. MRI of the brain can reveal
extensive white or deep grey matter lesions. Diagnosis of post-vaccination ADEM is based on clinical and
radiological features after recent exposure to vaccines and having excluded infectious etiologies.
Treatment options include steroids, plasma exchange and immunoglobulins. Most patients completely
recover within 1-6 months of treatment. In summary, for patients with altered consciousness and
multifocal findings after recent vaccination, the differential diagnosis should include post-vaccination
encephalomyelitis as early recognition is essential for full recovery.
Poster Finalists
Papillary Muscle Rupture with Severe Mitral Regurgitation Following Non-ST
Segment Myocardial Infarction: A Rare Complication
First Author: Kumar Sanam, MD Final Author: Narinder P Bhalla, MD
INTRODUCTION: Papillary muscle rupture is a well-known mechanical complication of ST Segment
Myocardial Infarction .Presented is a rare case of Ischemic necrosis of papillary muscle following Non ST
Segment Myocardial Infarction (NSTEMI).
CASE: A Seventy year old female presented to the hospital with chest pain. She was hemodynamically
stable with normal cardiovascular examination. Laboratory work revealed elevated troponins without
any evidence of ST segment or Q wave abnormality on electrocardiogram. Subsequently, she underwent
left heart catheterization which showed normal contrast ventriculography and 80% obstruction of LAD
(Left anterior descending) and RCA (right coronary artery). She was discharged after successful
revascularization of LAD and RCA with medically optimized treatment for NSTEMI. One week later, she
was readmitted with progressive dyspnea, weakness and orthopnea .She was tachycardic. A loud pan
systolic murmur at mitral area radiating to axilla and bibasilar crackles were audible on examination.
Laboratory work revealed elevated Pro BNP, trending down troponins and prominent interstitial
markings on Chest radiograph (prominent on right side). Both transthoracic and trans esophageal
Echocardiogram demonstrated flail posterior mitral leaflet, severe MR(Mitral regurgitation) with
ejection fraction of 65% (negative for vegetation).The diagnosis of severe MR with preserved systolic
function was made .Repeat left heart catheterization revealed patent stents in LAD and RCA with TIMI 3
flow. The patient underwent Mitral valve replacement .Intra operatively rupture of posterior papillary
muscle was confirmed. Pathological examination of excised tissue was consistent with infarcted cardiac
tissue. The postoperative course was uncomplicated and clinical improvement seen.
DISCUSSION: Mitral regurgitation is a known mechanical complication of trans mural infarction (STEMI)
.Acute mitral regurgitation with papillary muscle rupture has never been reported in our review of
literature in a patient with NSTEMI, patent vessels and normal ventricular function. Patient presents
with symptoms of heart failure within a week of myocardial infarction .A loud systolic murmur in the
mitral area should raise the possibility of acute MR which should be confirmed with an echocardiogram
.The precise diagnosis of papillary muscle rupture can be difficult to establish by transthoracic
echocardiography, as the ruptured head may not prolapse into the left atrium, making trans esophageal
echocardiography a more sensitive and useful tool for diagnosis. Systolic function is preserved in most of
the cases .The resulting valvular incompetence must be corrected by urgent mitral valve replacement
.Surgical survival did seem to be related to the extent of papillary muscle rupture, with the best results
occurring in the group with a small portion of the tip ruptured.
Conclusion: Given this case, mitral regurgitation with papillary muscle rupture should be suspected in a
patient with acute symptomatic heart failure and recent history of NSTEMI.
A Young Man with Fever and Eosinophilia
Nilay Kumar, MD, Brian C. Davis, BS, Nicholas Van Wagoner, MD, Jessica S. Merlin, MD, Ricardo La Hoz,
MD, Amy P. Hsu, BA, Mary Hanks, BA, Elizabeth P. Sampaio, MD, PhD, Christa S. Zerbe, MD and Steven
M. Holland, MD
Case: A 24-year-old man of African-American and Asian descent with no past medical history presented
with three weeks of fever, myalgias, and night sweats. He had headaches, right-sided facial numbness,
pleuritic chest pain and dyspnea two weeks before admission. He smoked marijuana and drank alcohol
occasionally. He was from Florida with no travel history. On examination, fever of 103°F, tachycardia and
pericardial friction rub were noted. Tender inguinal and axillary lymphadenopathy was present along
with subcutaneous nodules in the right deltoid, supraspinatus and paraspinal muscles. WBC count was
27x103 /mL with 28% eosinophils. TroponinI was 2.4 ng/ml. Chest CT showed a 2 cm right lower lobe
cavitary lesion. MRI of brain and right shoulder showed thick walled rim enhancing lesions in the
anterior temporal lobe, deltoid and supraspinatus muscles. Cardiac MRI showed myopericarditis,
pericardial effusion and tamponade necessitating pericardial window procedure. Deltoid muscle and
lymph node biopsy showed an eosinophilic infiltrate and aseptate fungal hyphae with right angle
branching consistent with fungi of the order Mucorales. Liposomal amphotericin B (7.5mg/kg/day) and
micafungin (150mg/day) were initiated. Blood and tissue culture grew Apophysomyces trapeziformis.
Complement, immunoglobulin and mannose binding lectin levels were normal. Tests for chronic
granulomatous disease and Hyper IgE syndrome were negative. Testing of the Interferon/ Interleukin12/ Interleukin-23 (IFN/IL-12/IL-23) signaling pathway showed a novel gain of function mutation in the
signal transducer and activator of transcription (STAT) 1 gene (c.1110G>C causing p.E370D). Low dose
IFNgamma subcutaneously three times weekly was started to augment cellular immune response. Oral
posaconazole (200mg every 6 hours) was started after completing 8 weeks of Amphotericin
B/Micafungin. Imaging studies 4 weeks after discharge showed decreasing size/number of lesions along
with improvement in symptoms.
Discussion: Apophysomyces trapeziformis is a recently described fungus of the class zygomycetes which
rarely infects humans. A PubMed search showed a total of 15 cases of A. trapeziformis infection treated
with extensive tissue debridement and liposomal amphotericin B in combination with posaconazole,
micafungin or voriconazole. All infections were attributed to injuries sustained in an EF5 tornado in
Joplin, Missouri in 2011.
STATs 1-6 are crucial proteins in the signal transduction pathway of IFN, IL-12 and IL-23 which control
cell mediated immunity. Gain of function (GOF) mutations in STAT1 are associated with chronic
mucocutaneous candidiasis, disseminated coccidioidomycosis and disseminated histoplasmosis, while
loss of function or dominant negative mutations are associated with viral and mycobacterial infections.
The GOF mutations are characterized by impaired production of IFNgamma, IL-17 and IL-22. This is the
first report of disseminated A. trapeziformis in association with GOF STAT1 mutation. Fungal infections
should be considered when evaluating patients with abscesses, fever and eosinophilia. A comprehensive
evaluation for underlying immunodeficiencies should be undertaken when evaluating apparently
healthy individuals with unusual infections.
The Mystery of Multiple Brain Masses
First Author: Pooja Sethi, MBBS Ankit Madan,MBBS Philip Putnam,MD
INTRODUCTION: Intracranial lesions in adults are most often due to metastatic disease or infection. In
the absence of primary tumor found elsewhere or signs of systemic infection, imaging studies may not
provide sufficient evidence and brain biopsy is necessary to reach a definitive diagnosis.
CASE REPORT A 71 year-old man presents with a 2 month history of aphasia. He was evaluated by a
neurologist 2 weeks after symptom onset. Initial CT imaging showed multiple scattered brain masses
which were concerning for metastasis vs infection. A CT of his chest, abdomen, and pelvis did not reveal
a primary tumor. The patient had a 30 pack-year smoking history, and underwent bronchoscopy and
bronchoalveolar lavage as part of his workup. Lavage fluid stained positive for cryptococcus. A
presumptive diagnosis of disseminated CNS Cryptococcus was made and the patient was started on IV
antifungal therapy.
The patient’s condition worsened, he developed progressive limb weakness, bowel and bladder
incontinence, and kidney failure. A repeat CT scan within 2 weeks showed increasing size of old lesions
and some new lesions scattered in the temporal and parietal lobes, as well as the cerebellum. He
underwent a brain biopsy which was negative for infectious agents, but showed hypercellular tissue
with scattered lymphocytes, concerning for low-grade glioma or reactive gliosis. Neuropathologic
examination revealed anaplastic astrocytoma WHO grade III. The tissue was negative for IDH 132
mutation. The cancer progressed and the patient died within 4 weeks of diagnosis.
DISCUSSION: Anaplastic astrocytoma (AA) is a WHO grade III brain glioma. Symptoms are caused by
local brain invasion and increased intracranial pressure, producing headache, nausea and papilledema.
Headache and seizure are the most common symptoms, occurring in about half of the cases. Other
symptoms seen in 20% patients include memory loss, motor weakness, language deficit, and cognitive
and personality changes.
AA are mostly solitary lesions involving the white matter of the cerebral hemispheres. Our patient
presents in a highly unusual fashion, with symptom onset and rapid deterioration clinically and on
imaging, in 2 months with multiple rapidly growing lesions involving both the cerebral lobes and the
cerebellum being found.
Imaging can often be misleading in such cases and stereotactic brain biopsy and histopathology is the
gold standard to reach a diagnosis and should be pursued early on in the work up. Specialized
immunochemical staining demonstrated absence of a 1p19q deletion and IDH132 mutation. When the
deletion occurs, patients have a better prognosis and respond better to treatment. The absence of this
deletion leads to rapid growth and worse outcome, as was the case in our patient.
First Author: Jawairia Memon, MBBS Second Author: Hareesh Gundlapalli, MBBS
Though angioedema involving face, skin and less commonly the airway is a well-known side effect of
angiotensin converting enzyme inhibitors, visceral angioedema has been rarely reported in literature.
Here we report an interesting case involving small bowel.
A 43 year old African American female recently diagnosed with hypertension presented with 1-day
history of abdominal pain, nausea, vomiting and non-bloody diarrhea. Symptoms developed after eating
turkey at the hospital cafeteria. She also has type 2 diabetes and stable asthma and takes lisinopril,
hydrochlorothiazide and metformin.
She was afebrile with normal vital signs. Physical exam significant for tenderness in left lower quadrant
without guarding or rebound. Labs including CBC, electrolytes, LFT's, lipase and ESR were normal. A CT
scan of abdomen and pelvis with contrast revealed thickened small bowel loops and moderate ascites.
Stool studies including C. difficile, were negative. Patient was started on metronidazole and levofloxacin
for possible infectious enteritis and sent home.
Three weeks later, she again presented with abdominal pain, bloating and diarrhea without fever.
Repeat CT scan again showed similar findings as above. Routine labs, C1 esterase, anti-gliadin
antibodies, and anti-transglutaminase antibodies were normal. The patient was evaluated with EGD,
colonoscopy and biopsies from stomach, duodenum, jejunum, colon and ileum showed no
histopathologic alterations. A diagnostic laparoscopy with multiple biopsies from small bowel, colon,
and liver was normal too. Later small bowel edema secondary to ace inhibitors was suspected and
lisinopril was discontinued. Patient's symptoms resolved after stopping lisinopril and a repeat CT scan
four months later showed resolution of bowel wall thickening and edema.
Over 40 million people worldwide are on ace inhibitor therapy and their use is increasing with the
increasing prevalence of diabetes, hypertension, and heart failure. Angioedema is well known side effect
of ace inhibitor from delayed breakdown of bradykinin. Approximately 30 % of all ED visits for
angioedema are secondary to ACEI. Mostly patients present with angioedema involving face and upper
respiratory tract. Patients with history of hereditary or idiopathic angioedema are at increased risk.
Several case reports have also demonstrated that patients of African American origin have significantly
increased risk. Small bowel angioedema is a less known side effect of ace inhibitors. Patient can present
with episodic abdominal pain, nausea, vomiting and loose stools. Presentation and radiologic findings
can mimic ischemic bowel disease, enteritis, and celiac disease. As there is no time correlation between
starting the medicine, duration of use, and onset of side effects, small bowel edema secondary to ace
inhibitors should be included in differential, if other workup is found to be negative.
An uncommon CAUSE OF cholestatic hepatitis – Epstein Barr Virus
Mohan Kumar MD, Kevin Olden MD.
Introduction: Epstein–Barr virus (EBV) infection is well known to cause the typical infectious
mononucleosis syndrome with symptoms of fever, pharyngitis, lymphadenopathy, and
hepatosplenomegaly. Sometimes it causes acute hepatitis, which is usually self-limiting, with mildly
elevated transaminase levels, but symptomatic hepatitis is rare. Cholestatic hepatitis with jaundice is
even more rare. In a recent, retrospective analysis of 1995 patients with jaundice in Cornwall, England,
only 17 (0.85%) had active EBV infections. (1) Here, we report a case of acute cholestatic hepatitis
secondary to EBV infection without the mononucelosis syndrome.
Case Description: A 26 year-old caucasian female with a history of a rare genetic disorder – N-Acetyl
Glutamate Synthase defiency, diagnosed in childhood -- and bronchial asthma, presented with a four
day history of right upper quadrant abdominal pain, nausea, fever and constipation. Immediately
preceding the abdominal pain, she reported experiencing “a cold”, with a sore throat and cough that
had lasted 3 weeks. She was given Augmentin for this by her primary care provider and had completed
the course 2 weeks prior to presentation.
She denied having any rash, vomiting or sick contacts and had recently had a menstrual period with a
history of regular cycles. She was noted to be afebrile and icteric on examination with a heart rate of
118. Her abdomen was soft, but tender to palpation in the right upper quadrant without guarding,
rebound or discernible organomegaly. All other systems were normal on exam, except for a spastic
diplegia which she had suffered from since childhood. Blood tests revealed AST:317, ALT:296, ALP:282,
Total Bilirubin 8.4, Direct Bilirubin 5.3.
A right upper quadrant ultrasound showed slight hepatosplenomegaly with no evidence of biliary
stones or biliary dilation. Viral Hepatitis panel was negative. A vasculitis panel including ANA, antidsDNA, anti-microsomal, anti-MPO, anti-smooth muscle antibodies, anti-Ro, anti-La, anti-Jo and antiproteinase 3 were all negative. Ceruloplasmin levels were normal. A viral panel was negative for all
viruses except EBV anti-capsid IgM antibody which was positive with a titer of 200 copies/ml by PCR.
The patient was treated conservatively and improved clinically and biochemically with almost complete
normalization of her liver function after a week of hospitalization.
Discussion: EBV is a ubiquitous virus of the herpes family and it is estimated that up to 90% of the
population are asymptomatic carriers of the virus.(2) Transmission by blood transfusion (3) and from a
transplanted organ in a previously seronegative recipient (4) have been documented. Relatively few
cases of EBV related cholestatic hepatitis have been reported (5). In the largest series identified by the
retrospective analysis of 1995 patients with hepatitis, only 17 (0.85%) had EBV hepatitis (1). The median
age was 40 years (range 18–68 years). Ten of 17 (59%) patients were aged >30 years, and seven of 17
(41%) patients were aged ≥60 years. Fifteen of 17 (88%) patients presented with clinical/biochemical
evidence of jaundice.(1) It is notable that our patient did not have the mononucleosis syndrome with
lymphocytosis. The clues to the diagnosis included the presence of fever and splenomegaly, with
symptoms suggestive of a preceding viral prodrome.
EBV hepatitis should be considered in the differential diagnosis of all patients with hepatitis, without a
clearly identified etiology.
1. Vine, L. J., Shepherd, K., Hunter, J. G., Madden, R., Thornton, C., Ellis, V., Bendall, R. P. and
Dalton, H. R. (2012), Characteristics of Epstein–Barr virus hepatitis among patients with jaundice
or acute hepatitis. Alimentary Pharmacology & Therapeutics, 36: 16–21.
2. Macsween KF, Crawford DH. Epstein-Barr virus-recent advances. Lancet Infect Dis. 2003;3:131–
3. Paloheimo JA, Halonen PI. A case on mononucleosis-like syndrome after blood transfusion from
a donor with symptomatic mononucleosis. J Cardiovasc Surg (Torino) 1965;6:558–561.
4. Cen H, Breinig MC, Atchison RW, Ho M, McKnight JL. Epstein-Bar virus transmission the donor
organs in solid organ transplantation: polymerase chain reaction and restriction fragment length
polymorphism analysis of IR2, IR3 and IR4. J Virol. 1991;65:976–980.
5. Lawee D. Mild infectious mononucleosis presenting with transient mixed liver disease. Can Fam
Physician. 2007;53:1314–1316.
Pierce, MD
65-year-old female with multiple thromboembolic events
Matthew Pierce MD, Ryan Kraemer MD
Case Presentation: A 65-year-old woman presented to the emergency departmentwith severe left arm
pain for several hours. The throbbing pain awoke her fromsleep, and her hand was becoming numb. On
exam her left hand was cool and pale,and upper extremity pulses were not palpable. Her medical
history was notable only for an ischemic stroketwo months prior when she presented with right arm
weakness. Imaging at thattime was consistent with embolic origin, but evaluation for a cardiac source
orhypercoagulable state was negative. She was taken emergently for surgical revascularization andhad
embolectomies of the left subclavian, brachial, and ulnar arteries. Whilerecovering from anesthesia she
became unresponsive, and imaging revealed alarge posterior circulation stroke. Later the patient’s
family elected towithdraw care due to her poor prognosis.Autopsy was performed, revealing a 3cm
intraluminal massarising from the wall of the aorta at the aortic arch. Pathologic examinationof the
tumor was consistent with angiosarcoma. Tumor emboli were presentthroughout the cerebral and
upper extremity vasculature.
Discussion: This patient suffered multiple thromboembolic events withina short period of time. In
particular she had two ischemic strokes and acutelimb ischemia, all due to emboli in the arterial
circulation. Arterial emboliare most commonly cardiac in origin, from conditions such as atrialfibrillation,
valvular disease, cardiomyopathy, or endocarditis. Paradoxicalemboli may come from the venous
circulation due to septal abnormalities. Embolican also arise from an aortic source, such as plaque,
thrombus, or tumor.Aortic tumors are uncommon, but can lead to embolic events.This patient had an
aortic angiosarcoma presenting with tumor emboli to theupper extremity and cerebral circulation.
Angiosarcomas are malignant vasculartumors of endothelial origin which rarely involve the aorta, with
less than 40reported cases. They can presentwith embolic phenomena, as in this case, or symptoms of
aorto-iliac occlusivedisease. Diagnosing aortic tumors is challenging due to the rarity of thediagnosis and
non-specific symptoms. Magnetic resonance angiography (MRA) isthe recommended imaging modality,
but transesophageal echocardiogram (TEE) canalso detect lesions of the thoracic aorta. Treatment
consists of surgicalresection, often with adjuvant radiation or chemotherapy. Prognosis is poorwith an
average survival of approximately one year. Although aortic tumors are rare, it is important to
consideraortic disease as a cause of arterial embolic events, especially in the absenceof a cardiac source.
Bamboozled by Syncope
Jonathan A. Olsen, D.O. Banner Good Samaritan Medical Center, Department of Internal Medicine,
Phoenix, AZ; Lise Harper, M.D. Banner Good Samaritan Medical Center, Department of Internal
Medicine, Phoenix, AZ; Brenda Shinar, M.D. Banner Good Samaritan Med
Introduction: Amyloidosisrefers to the group of disorders that share the common feature of
insolublefibrillar protein deposition into organs and tissue. Though a rare condition,unless considered, it
may go undiagnosed. Properly categorizing amyloidosisinto one of three major categories can help with
selecting an appropriatediagnostic approach.
Case Presentation: A 57-year-old female with no significant past medical history presented
forexpedited workup of her neuropathy and severe orthostatic hypotension. Sheendorsed a one-year
history of increasingly severe bilateral lower extremity pain, burning and numbness, starting in her toes
and extending proximally to hermid-calf. Additionally, she complained of lightheadedness on standing
andoccasional syncope, becoming more frequent and debilitating over the past fewmonths prior to
presentation. Home blood pressure readings were as low as 40/30 mmHg standing. Shewas started on
gabapentin for the neuropathy and fludricortisone andmidodrine for the orthostatic hypotension.
She underwent an extensive workup prior to admission to our facility. Neurologic workup, including
MRIand MRA of the head and neck, electromyography, tilt table testing and suralnerve biopsy failed
to demonstrate a definitive diagnosis. Extensive endocrine and cardiacworkup were also unrevealing.
On presentation, physical exam was significant fororthostatic hypotension without a change in her heart
rate. Neurologic examrevealed decreased pinprick sensation on the feet bilaterallyand absent vibratory
sensation in the toes. The differential diagnosis of acombined peripheral and autonomic neuropathy
remained broad, includingmultiple system atrophy, Lewy body disease, vitamin B12 deficiency, multiple
sclerosis, paraneoplastic neuropathy, autoimmune autonomic neuropathy andamyloidosis. Additional
workup, including a fat padbiopsy in search of amyloidosis, was negative. However, when the
transthyreitinantibody testing resulted as positive, additional investigation ensued. The
patientunderwent endomyocardial biopsy, which confirmed transthyreitin related antibody or familial
amyloidosis, a hereditary disease.
Discussion: Though fat pad biopsy is oftenemployed in the initial workup of amyloidosis, a negative
result and highclinical suspicion should warrant further investigation. Subsequent testingshould be
chosen based on which category of amyloidosis is suspected. Primary (AL) amyloidosis, which results in
monoclonalimmunoglobulin light chain deposition, is related to multiple myeloma and fatpad aspirate is
positive in 90% of patients with AL amyloidosis. Additional key diagnostictesting includes serum and
protein electrophoresis and bone marrow biopsy withstaining for alpha and kappa light chains.
Secondary (AA) amyloidosis, oftenassociated with an underlying autoimmune disorder, can be
diagnosed by fat padbiopsy and further staining for serum amyloid A protein. Familial amyloidosis
(ATTR), distinguished by deposition of the transthyreitin protein, can bediagnosed by serum
transthyreitin testing or DNA-based testing for a mutanttransthyreitin gene. Notably, fat pad biopsy is
only 70% sensitive in thisgroup and a negative fat pad biopsy should promptfurther investigation if
familial amyloidosis is high on the differential.
Statins and autoimmune disorders - A less known and potentially fatal
First Author: Preethi William, MBBS Second author: Santhosh G John MD
Introduction: Statins are widely prescribed medications with documented cardiovascular benefits.
Statins are known to cause myositis, but their association with autoimmune disorders is rarely reported.
We report a case of an apparently healthy 76 year old female who was on long term statin therapy
presenting with severe rhabdomyolysis, autoimmune hepatitis and positive Lupus antibodies.
Case description: Our patient is a 76 year old woman with history of hypertension, dyslipidemia and
diet controlled diabetes mellitus. She was admitted to the hospital with complaints of worsening
fatigue, leg cramps and progressive weakening of lower extremities over three weeks. She also noticed
increasing leg swelling, abdominal distension and jaundice over the same period. The patient was
otherwise asymptomatic, prior to the onset of her symptoms. The patient was on simvastatin 80 mg
daily for several years.
Clinical examination findings on admission included icterus, severe tenderness of extremity
musculature, lower extremity edema and ascites. Her admission labs showed creatinine kinase of 29000
IU/dL, AST 2516 IU/dL, and ALT 957 IU/dL. IgG antibody titer was 3831 mg/dL. Viral hepatitis panel was
negative. Immunological work up revealed positive ANA, anti-ds DNA, anti-SSA antibodies and negative
anti–smith antibody. F-actin antibody, which has been shown to have great sensitivity and specificity in
autoimmune hepatitis, was also highly positive. MRI of the lower extremities showed findings,
consistent with myositis. CT scan of the abdomen with contrast showed findings suggestive of early
cirrhosis. Patient underwent biopsy of the thigh muscles which showed inflammatory myositis. Patient
also underwent liver biopsy with histopathological staining characteristic of autoimmune hepatitis.
Patient was treated with intravenous fluid, immunosuppressive therapy with Azathioprine and
prednisone, which was gradually tapered to a lower maintenance dose. At follow up her myalgia and
myopathy had resolved. Liver function tests had also returned to normal.
Discussion: Autoimmune disorders like hepatitis, SLE and Dermatomyositis are uncommonly associated
with statins. Reports on Medline Data search since 1966 have shown only 28 reported cases of statin
induced lupus like syndrome. There were 2 cases of autoimmune hepatitis reported in patients with
possible statin induced SLE. We report this case to highlight this association and educate the clinician to
consider this in the differential when evaluating and treating a patient presenting with autoimmune
disorders. Although our patient did not have the florid clinical findings of SLE, close monitoring for
development of Lupus like syndrome is warranted in this scenario. Systemic immunosuppressive therapy
has proven to be effective in many reported cases.
Gastrointestinal Basidiobolomycosis, An Emerging Fungal Infection In the
Southwest USA
First Author: Razan A El-Ramahi, MBBS Second Author: Joel A Terriquez, MD
Introduction: A 34 year old female presented with two-week history of intermittent abdominal pain and
fever. Pain was described as right lower quadrant, progressively worsening and with no radiation. She
has a past medical history of D.M., developmental delay and GERD. Upon admission she was febrile,
had RLQ tenderness and was found to have elevated WBC count of around 14,000, 17% eosinophils. An
abdomen/pelvic CT scan showed perforated appendicitis, with abscess formation, measuring up to 5.7
cm. IR drainage attempted but no aspiration or drainage performed. Biopsy specimens came back with
no growth.
Case Presentation: She failed to improve with recurrent fever and persistent leukocytosis. Repeat CT
scan showed stable right lower quadrant mass and abscess. Repeat IR drainage grew CONS,
Lactobacillus and a mold. Patient was continued on IV antibiotics and discharged home on oral
antibiotics with the drain in place. Follow up at the surgery clinic with an abscessogram revealed a
colocutaneous fistula. Exploratory laparotomy, ileocecectomy and intra-abdominal abscess drainage
were done. Specimens were sent for pathology. Pathology showed necrotizing fungal (extensive)
granulomatous inflammation and fungal hyphae consistent with Basidiobolus. Fungal culture from her
previous admission was identified as Basidiobolus spp. She was placed on oral itraconazole, improved
and discharged home. Basidiobolus ranarum is an environmental saprophytic fungus found worldwide in
soil, decaying organic matter and as a commensal in the intestinal tract of amphibians, fish and reptiles.
Infections usually present with subcutaneous nodules and commonly found in tropical areas of South
America, Africa and Asia. Gastrointestinal involvement with invasive Basidiobolus infection has been
rarely described in the literature. It was noted to be an emerging infection in Southwestern United
States. A recent review examined 44 reported cases from around the world. Nineteen (43%) were from
the United States, seventeen were residents of Arizona, one was from a Southern Utah and one was
from Florida. No patients were immunocompromized. The most common presenting symptom was
abdominal pain. Peripheral eosinophilia was noted in 26 patients (76%) and the most common imaging
finding was a mass followed by bowel wall thickening. The initial provisional diagnosis in most of those
patients was intraabdominal malignancy or inflammatory bowel disease.
Discussion: The typical histopathological feature is necrotizing granulomatous inflammation containing
thin-walled, broad, aseptate hyphae with a surrounding eosinophilic sheath, known as SplendoreHoeppli phenomenon. Confirmatory fungal cultures and fungal staining should always be done on
biopsy specimens from unusual gastrointestinal masses. Sabouraud agar is an adequate medium, and
visible growth is usually present within 2–3 days. Visceral Basidiobolomycoses are rare and still not well
understood but should be suspected when a patient presents with abdominal complaint(s) along with
elevated WBC count, eosinophilia and mass or thickening in the gastrointestinal system and fail to
improve with conventional therapy.
Guru Murthy, MD
Myocardial infarction
Guru Subramanian Guru Murthy MD1, Amit Bahia MD2, J.L.Mehta MD2
Department of Internal Medicine1 , Department of Cardiology2
University of Arkansas for Medical Sciences, Little Rock, AR
Introduction : Myocardial infarction (MI) is a rare disease in young adults. Various conditions like
premature atherosclerosis, coronary thrombosis, embolism are known to cause MI in young adults.
Case description : 29-year-old male who works as a mason, presented with history of nausea, vomiting,
muscle cramps and pain all over the body after his work on a hot summer day. On examination, his
temperature was 99.9 0F and had clinical features of dehydration and diffuse muscle tenderness.
Pertinent lab findings were Hb 17 g/dl, WBC 24,100 cells/mm3, BUN 24 mg/dl, Serum creatinine 3.4
mg/dl, CK total 684 U/L, CK-MB 19.9 U/L, Troponin I 0.34 U/L. Lipid profile was normal. His urine drug
screen was positive for opiates, THC and amphetamine. The initial ECG revealed sinus bradycardia.
Patient was initially diagnosed to have rhabdomyolysis with acute kidney injury and treated with
intravenous normal saline.
Laboratory tests after 12 hours revealed decline in serum creatinine to 1.2 mg/dl and striking increase in
total CK (3739 U/L), CK-MB (235 U/L), Serum troponin I (63.5 U/L). Subsequent ECG showed T wave
inversion in inferior leads. 2D echo revealed segmental hypokinesia involving the basal mid-inferoseptal
and inferolateral wall . An emergent coronary angiogram was performed which revealed a completely
normal coronary tree except for a large thrombus in mid- right coronary artery. Thrombectomy was
performed and the patient was later discharged.
Discussion : Heat exhaustion is characterized by core temperature between 37°C to 40°C with dizziness,
thirst, weakness, headache, and malaise. Patients with heat related illness often have features of muscle
injury and renal dysfunction. Serum troponin could be elevated as a result of generalized muscle
damage and renal dysfunction. Amphetamine use has also been reported to be associated with
In previous reports, cardiac troponin was elevated as a marker of myocardial injury in acute
rhabdomyolysis, however its association with myocardial infarction was variable. In our patient,
elevated troponin level was initially attributed to renal injury. Our patient had neither typical angina
symptoms nor ECG changes on admission to suspect myocardial infarction during initial evaluation.
In this patient, stress from the acute dehydration could have provoked coronary thrombosis. Secondly,
myocardial infarction could also be attributed to illicit drug abuse in this patient. Cannabis,
amphetamines, and cigarette smoking can cause myocardial infarction due to transient formation of
thrombus and/or coronary spasm. Thirdly, rhabdomyolysis could have been contributory to the
coronary thrombosis as its manifestation in the heart.
Tick, Tick, Tick: Anaplasmosis in Northern California
Jeanne Lee MD, Susanna Tan MD, David Busch MD
Introduction: Anaplasmosis (Human granulocytic Ehrlichiosis) is rarely seen in California. We describe
three cases identified in Northern California in 2012.
Case Presentations: A 61-year old woman presented in May 2012 with fever, generalized weakness,
muscle aches, and upper abdominal pain for 2 weeks. She was an avid hiker, most recently at Point
Reyes National Seashore. She did not recall recent tick bites. Initial labs were significant for
thrombocytopenia (nadir of 32,000) and elevated liver enzymes (AST 349, ALT 278, alkaline phosphatase
284). Doxycycline treatment was started, and she quickly defervesced over the next few days.
Anaplasma phagocytophilum serologies showed an IgM titer of 1:160 (normal < 1:20) and IgG 1:1024
(normal <1:64).Two other similar cases were seen at our hospital within a month of this case. A 79-year
old woman developed nearly identical symptoms within two weeks after hiking in San Mateo County.
Platelet count was 21,000 and AST was 65. Blood smear showed numerous neutrophils, a few with
atypical cytoplasmic inclusions consistent with morulae (clumps of Anaplasma organisms). IgM and IgG
antibodies to A. phagocytophilum were detected in a convalescent specimen drawn 3 weeks after the
start of treatment.
The third patient was a 42-year old man who developed shaking chills, high fevers, headaches, and sinus
pain after running in the Marin Headlands. Empiric treatment with azithromycin resulted in transient
defervescence, but fevers returned along with chills and drenching night sweats. Antibodies to A.
phagocytophilum and E.chaffeensis were both positive, with an IgM of =1:320 and IgG of 1:256 for the
former, and IgM of 1:20 and IgG of 1:256 for the latter.
All three patients recovered completely with doxycycline treatment. All three cases were reported to
the California Department of Public Health, but only the case of the 79 year old was confirmed because
of her rise in titers. Only one additional case has been reported in Northern California this year.
Discussion: Anaplasma phagocytophilum is a Gram-negative bacterium that invades and replicates
inside granulocytes. It is most commonly transmitted to humans by the bite of the nymph or adult
black-legged tick (Ixodes scapularis in the Midwest/Northeast and Ixodes pacificus on the West Coast).
Anaplasmosis is most frequently reported in the upper Midwestern and northeastern United States,
with 1.6 cases per million during 2001 to 2002. Only 13 cases were reported in California between 1994
and 2006, but 6 were confirmed. Symptoms of fever, headache, malaise and myalgias are nonspecific,
and a history of tick bite is often not present. Leukopenia, thrombocytopenia and transaminitis are the
most common laboratory abnormalities. Clinicians should consider tick-borne disease including
anaplasmosis in patients with an acute febrile illness and seasonal outdoor exposure in Northern
Scott, MD
A Rare Cause of Right Upper Quadrant Abdominal Pain
First Author: Amanda Lynn Scott, MD Second Author: Soujanya Sodavarapu, MD Third Author: Stephen
Hosea, MD
Introduction: Right upper quadrant (RUQ) abdominal pain is often associated with biliary, hepatic or
gastrointestinal ailments. This case demonstrates a patient who presented with severe RUQ pain and an
initially negative workup. Only after closely reviewing her history of transient upper back pain, was it
discovered that vertebral osteomyelitis with radiculopathy was the cause of this patient’s abdominal
Case report: This patient is a 50-year-old female with a history of right lower extremity osteomyelitis
who presented to the emergency department (ED) with acute onset of upper back pain and shortness of
breath. In the ED, her vital signs were normal and her white count was noted to be 14.2 with 30%
bands. In addition, her CRP was elevated at 162. The patient had a chest x-ray and CT of the chest with
contrast; both studies were unremarkable. The patient was started on broad spectrum antibiotics and
admitted. The next morning, her back pain had resolved, but in its place, a sharp, RUQ abdominal pain
began. This pain did not radiate, was constant, and was not associated with nausea, vomiting, diarrhea
or constipation, but she did complain of a decreased appetite. On exam, she was extremely tender in
the RUQ and was guarding on palpation. The pain was exacerbated by deep breaths, but murphy’s sign
was negative. Her liver enzymes, liver function tests and ultrasound of the abdomen were normal. She
had a HIDA scan that showed patent ducts. Upper Endoscopy also showed no abnormalities. The
patient was requiring high doses of I.V. morphine and a proton pump inhibitor did not offer any relief.
At this point, a closer review of her initial presentation with transient back pain lead to obtaining an MRI
of spine focusing on T6-T8 levels. The MRI revealed early discitis/osteomyelitis at T5-T7. Given her
chronic osteomyletitis and many debridements, likely a bacteremia had seeded the vertebral bodies and
the disc. The patient was started on I.V. toradol, and her RUQ pain significantly improved. Both her
blood cultures and her wound culture grew group B streptococcus which was consistent the likely
etiology. The patient was then discharged with 6 weeks of I.V. antibiotics and outpatient follow up.
Discussion: Right upper quadrant pain is a common complaint and is immediately associated with
diseases such as cholecystitis, hepatitis and biliary colic. Other causes such as pneumonia or
subdiaphragmatic abscess are also considered by most physicians. But sometimes when the etiology
remains elusive, one needs to closely review the case and consider other, more unique causes of
abdominal pain such as vertebral osteomyelitis.
Tumor Lysis in a Solid Organ Malignancy
First Author: Ronald Kall, MD Second Author: Cynthia Ho MD Third Author: Jeffery Canceko MD
Tumor lysis syndrome is a clinical constellation of electrolyte abnormalities related to massive tumor
cytolysis resulting in acute uremic nephropathy. Tumor lysis syndrome is an oncologic emergency and
requires urgent diagnosis and treatment. The condition is seen in hematologic malignancies such as
acute leukemia and lymphomas, especially during induction chemotherapy. It is seen rarely in solid
organ tumors with large tumor burden during chemotherapy. Only 45 cases were reported between
1977-2002 that demonstrate spontaneous tumor lysis syndrome with malignant solid tumor.
A 41 year old Hispanic male with no past medical history presented to the emergency room with right
upper quadrant abdominal pain for 5 days. A abdominal CT scan from an outside hospital demonstrated
multiple liver masses which were likely malignant. His hepatic workup was negative for viral hepatitis
and his history was not consistent with drug induced injury. A CT pulmonary angiography was performed
due to a concern for pulmonary embolism. It revealed an interval enlargement of the liver with
increased number and size of hepatic metastases.
An Ultrasound guided Liver biopsy confirmed the diagnosis of a metastatic poorly differentiated
adenocarcinoma with neuroendocrine features. One week after tissue diagnosis and staging, the patient
again presented to the emergency room with increased work of breathing, hypoxia, jaundice, and
increased abdominal girth. He was noted to be hyperkalemic with EKG changes. He was subsequently
intubated for respiratory failure. The patient also experienced a drop in his hemoglobin due to an acute
lower GI bleed. On admission to the MICU, the patient's uric acid was measured at 14.4. and his LDH had
risen dramatically since his last discharge. A diagnosis of tumor lysis syndrome was made. The patient
was aggressively fluid resuscitated and started on rasburicase. His labs from this point continued to
demonstrate a metabolic acidosis due to lactic acidosis and uremic nephropathy. Oncology, GI, Renal
and the inpatient primary ICU team agreed that no reasonable intervention could be performed and the
patient was to receive palliative extubation and withdrawal of care. The patient expired immediately
after care was withdrawn.
This case demonstrates a spontaneous solid organ tumor lysis most likely precipitated by heavy tumor
burden complicated by concurrent lower GI bleed at the site of the patient's primary tumor. The vast
majority of tumor lysis syndromes are usually intra or post-chemotherapy sessions and are far more
common in hematologic malignancies where the high amount of circulating tumor cells prime the
situation. This patient presented with the classical uremic nephropathy, hyperkalemia, lactic acidosis,
hypophosphatemia without having received any chemotherapy.
A “Queso fresco” conundrum—Acute hepatitis due to Brucellosis
First Author: Arta Lahiji, MD, Phuong-Chi Pham, MD, and Glenn Mathisen, MD
Case Presentation: This is the case of 32 year-old male with no significant past medical history who
presented with abdominal pain accompanied by a 20 lb. weight loss, a two month history of intermittent
high fever (up to 40° C) and night sweats. He works in southern California as a cook and denied a history
of travel, contact with farm animals or recent ingestion of raw milk or cheese. Vital signs demonstrated
fever to 40° C, BP: 117/73 mm Hg., heart rate of 76 bpm and RR:17.His physical examination was normal
except for a few small petechiae on the soft palate and a palpable spleen tip. Laboratory studies
revealed panyctopenia with white count 2.7 cells/mm3, hemoglobin 12.3 gm/dL and a platelet count of
100K. Liver tests were markedly elevated (AST 1038: ALT 1377: AP 310: TBil:1.4) and abdominal CT
revealed a mildly enlarged liver (20 cm) and splenomegaly (15 cm). Serological studies for viral hepatitis
were negative for acute or chronic infection. The patient was started on empiric broad spectrum
antibiotic therapy (vancomycin and cefepime) but he continued to remain febrile. On day 3, blood
cultures taken on admission were positive for small gram negative “coccobacillary” organisms (identified
as Brucella melitensis) and the patient was diagnosed with brucellosis. The patient’s antibiotic therapy
was then changed to intravenous gentamicin (5 mg/kg/day) and doxycycline (100 mg PO BID). Over the
next 4 days he had resolution of fever/symptoms and he was discharged on a planned 8 week course of
rifampin and doxycycline . On closer questioning, the patient stated that he loved dairy products and
frequently ingested “queso fresco” (raw cheese) from Mexico. At the five week follow-up, the patient
felt well and the abnormal laboratory results had completely resolved.
Discussion: Brucellosis is a zoonotic infection that is transmitted to humans after contact from infected
animals such as sheep, cattle, or goat, or from their food products such as unpasteurized milk and
cheese. It is sometimes called “undulant fever”, because of the intermittent, “undulating” quality of the
fever as seen in this case. In addition to constitutional signs (fever, weight loss, night sweats), brucellosis
can have multi-organ involvement including osteoarticular (SI joints, spondylitis), genitourinary
(epididymoorchitis), hematologic (leukopenia, anemia, thrombocytopenia), cardiac (endocarditis,
pericarditis), neurologic (meningitis, myelitis, radiculitis), ocular (uveitis), and dermatologic (petechiae,
ulcerations) manifestations. Mild liver enzyme elevation is common in brucellosis (50% of cases);
however, overt hepatitis, as in this case is much less common (5% of cases). Although uncommon,
consider the diagnosis of brucellosis in patients with unexplained fever and hepatitis, especially if there
is a history of animal exposure or ingestion of raw dairy products (milk/cheese).
Hubbard, DO
Cardiopulmonary Bypass And Aortic Balloon Counter-Pulsation In Amniotic
Fluid Embolism
First Author: Michael R Hubbard, DO Sudhir Rajan, MD; Hekmat Nasiri, MD
Introduction: Amniotic fluid embolism is a rare and catastrophic complication of pregnancy. It carries
an extremely high maternal and fetal morbidity and mortality. Clinical manifestation is often sudden and
protean. Immediate recognition and initiation of supportive therapy can lead to successful outcomes.
Case Description: We report a case of a 27-year-old Gravida3Para2 healthy woman who was admitted
for elective dilation and evacuation after routine obstetrical ultrasound determined intrauterine fetal
demise (IUFD) at 16-weeks gestational age. Pre-operative laboratories, including complete blood count
(CBC) and disseminated intravascular coagulation (DIC) panel, were normal. Twenty minutes into the
procedure, the patient developed sudden hypotension and bradycardia that rapidly progressed to
ventricular fibrillation arrest. Cardiopulmonary resuscitation (CPR) was initiated and she was intubated.
Labs drawn at the start of resuscitation were Hemoglobin11.0 (g/dL), INR 2.2, PTT 49.7, PT 22.4,
fibrinogen 204. Hemoglobin drawn 40 minutes later dropped to 5.8 (g/dL). Despite aggressive
resuscitative measures, the patient remained with pulseless electrical activity. The patient was placed
on cardiopulmonary bypass via open sternotomy and an intra-aortic balloon pump was placed. She
required massive transfusion in the OR with 34 units of pRBCs, 10 units of platelets, and16 units of FFP.
An intra-operative TEE showed dilated right ventricle with paradoxical septal motion and a left
ventricular ejection fraction (LVEF) of 20%. The patient was taken off cardiopulmonary bypass and the
chest was closed. She was transferred to the ICU with an intra-aortic balloon pump, and on multiple
vasopressors. By hospital day two, the patient was weaned off the intra-aortic balloon pump and
vasopressors. A perinatalology consult on hospital day two concluded the most likely etiology was
amniotic fluid embolism (AFE). The patient was extubated on hospital day three. The patient was
discharged without neurologic deficits after 10 days of hospitalization. Post-hospital follow-up
echocardiogram showed normalization of LVEF.
Discussion: AFE is the fifth leading cause of maternal mortality; with mortality rates as high as 80-90%
in some reports. Less than 15% of those few that survive are left without significant neurologic injury
from cerebral hypoxia. It has been suggested that the cardiovascular collapse often seen in AFE may be
the result of a secondary decrease in left ventricular function caused by an initial pulmonary
hypertension and hypoxemia leading to possible myocardial ischemia. Cardiopulmonary bypass allows
for the temporary circumvention of the pulmonary system while also providing time for the
spontaneous decay of inflammatory mediators possibly associated with severe pulmonary
vasoconstriction. Through the use of cardiopulmonary bypass and aortic balloon counter-pulsation, this
patient was able to survive neurologically intact. At this time, we have no means of foreseeing AFE or
preventing them for that matter. Therefore, we must learn from successful management of this truly
devastating malady.
Benhammou, MD
Aseptic meningitis: A rare presentation of SLE
First Author: Jihane Benhammou, MD Second Author: Magdalena Ptaszny, MD
Introduction: Systemic Lupus Erythematosus (SLE) is a multi-organ autoimmune process, therefore
having a wide range of clinical presentations. Neuropsychiatric Lupus Erythematosus (NPSLE) affects 1475% of adults afflicted with lupus[1]; however it is rarely the presenting symptom of SLE.
Case presentation: We report a case of a 33 year old female with a history of hypertension and
dyslipidemia who presented with progressive worsening of headaches and altered mentation. One
week prior to admission, she was diagnosed with migraines and was started on a triptan with no
improvement. She subsequently presented on several occasions to an outside hospital with worsening
headaches associated with nausea, vomiting and intermittent left-side hemiparesis. CT brain was
negative. However, thrombocytopenia was noted and she was started on prednisone for presumed
Idiopathic Thrombocytopenic Purpura. On the day of admission to our hospital, the patient was febrile,
had a tonic-clonic seizure with residual left-sided hemiparesis, and was noted to be altered. MRI
demonstrated meningo-encephalitis affecting most of the right cerebral sulci and a few superior left
occipital sulci, with swelling of the adjacent cortex. EEG was notable for severe diffuse slowing of the
right hemisphere. CSF studies showed no cells and an elevated protein level. Lab studies were positive
for thrombocytopenia, autoimmune hemolytic anemia, ANA of 1:1280 (homogenous pattern) and
dsDNA 243 (<200). She was diagnosed with NPSLE, treated with steroids and cyclophosphamide and
showed marked improvement.
Discussion: The prevalence of NPSLE is not well established due to its range of presentations and lack in
nomenclature consensus. Our patient was diagnosed with SLE by meeting 4 (ANA, dsDNA,
anemia/thrombocytopenia and NPSLE) of the 11 American College of Rheumatology criteria. Aseptic
meningitis rarely occurs in SLE (0.7%)[2]; although some populations suggest a prevalence of 1.2%[3]
early in SLE diagnosis. However, aseptic meningitis is rarely the initial presenting symptom. This
illustrates the importance of having a high index of suspicion for lupus in young otherwise relatively
healthy females with an atypical neuropsychiatric presentation.
[1] S.G. West, Lupus and the central nervous system. Curr Opin Rheumatol 8 (1996) p. 408.
[2] J.M. Kim, K.J. Kim, H.S. Yoon et al., Meningitis in Korean patients with systemic lupus erythematous:
analysis of demographics, clinical features and outcomes; experience from affiliated hospitals of the
Catholic University of Korea. Lupus 20 (2011) p. 531.
[3] J.G. Hanly, M.B. Urowitz, J. Sanchez-Guerrero J et al., Neuropsychiatric Events at the Time of
Diagnosis of Systemic Lupus Erythematous. Arthritis and Rheum 56 (2007) p. 265.
Hodgkin Lymphoma: A Novel Treatment Approach
First Author: Huynh Cao, MD Second Author: Kenneth Yamamoto, MD
Hodgkin lymphoma is classically characterized by malignant Reed-Sternberg cell with pathologic CD30
expression leading to secretion of survival factors and attracting inflammatory cells to their local
environment. Before the successful development of multi-agent chemotherapy, patients with
advanced-stage have really poor prognosis.
A 49 year old female presented with fever up to 103 for five days. In the ED, she underwent abdominal
/ pelvic CT which showed bilateral retroperitoneal lymphadenopathy and a hypodense hepatic lesion.
Given her classic “Pel-Ebstein-type fevers”, lymphoma was suspected. A PET – CT showed abnormal
FDG uptake consistent with widespread metastatic disease throughout the appendicular skeleton and
lymph node beds above and below the diaphragm. Bone marrow biopsy confirmed classical Hodgkin
lymphoma (cHL). She subsequently developed severe sepsis, disseminated lymphoma causing acute
renal failure, and acute respiratory failure from pulmonary hemorrhage. We believed that she would
not tolerate a standard regimen of multi-agent chemotherapy and elected treatment with multi-cycles
of brentuximab as first line agent, followed by a modified BEACOPP regimen. She tolerated the therapy
well and was eventually discharged from the hospital four weeks later with only minor peripheral
neuropathy. She was disease free at her recent one year follow-up.
Current National Comprehensive Cancer Network treatment guidelines for patients with stage III / IV
disease recommend ABVD or escalated BEACOPP chemotherapy as first line regimens, which have
achieved improved ten-year survival but have substantial hematologic and infectious toxicity as well as
an increased risk for secondary hematologist malignancy. Recent advancements in technology have
enabled an exciting shift to molecular target cancer therapy. Our patient was treated with brentuximab,
a new antibody-drug conjugate, anti-human CD30 antibody that binds to malignant cells and releases a
microtubule-disrupting agent intracellularly. A recent phase II open-label study of 102 patients with
relapsed / refractory cHL treated with brentuximab found an Objective Response rate of 75%; 34% of
patients achieved a Complete Response with a median Progression-free Survival of 21.7 months. These
statistical numbers are impressive given that these patients had failed a median of 3.5 chemotherapy
regimens and autologous stem cell transplant. Brentuximab is approved by the FDA for the treatment of
systemic anaplastic large-cell lymphoma and refractory Hodgkin lymphoma that has progressed after
autologous stem cell transplant, or after 2 prior multiagent chemotherapy regimens among patients
ineligible to receive a transplant.
Given the impressive response rate and favorable toxicity profile for brentuximab in patients with
relapsed / refractory cHL, several studies are researching its use as a first-line single agent or
incorporated into standard regimens such as ABVD. As we learn more about molecular target therapy, it
will change our approach to the treatment. Why settle for a standard treatment regimen when there is
a potentially equally effective molecular treatment with fewer side effects?
Sara Patrawala Resident, Department of Medicine, The University of California, San Diego, San Diego,
Compartment syndrome is a life and limb threatening condition that requires early diagnosis and
immediate surgical intervention. It is caused by increased tissue pressure with resulting neurovascular
compression and is commonly associated with trauma, re-vascularization of ischemic tissue, full
circumference burns, or heavy exercise. Leukemic infiltration is a rare cause of spontaneous
compartment syndrome.
A 54-year-old man with a recent diagnosis of chronic monomyelocytic leukemia (CMML) presented to
the emergency room with a 2-day history of severe right anterior shin pain. The patient was diagnosed
with CMML at an outside hospital three weeks prior detected initially on an abnormal peripheral blood
smear and confirmed on bone marrow biopsy. He was now presenting with severe pain without any
history of trauma. Vital signs on presentation were blood pressure 116/79mm Hg, heart rate 142
beats/min, respiratory rate 18 breaths/min and temperature 99.3 F. Laboratory studies revealed a
hemoglobin of 7.7 g/dL, white blood cell count of 6,100/uL and platelets of 155,000/uL. Exam was
notable for a tense anterior and lateral compartment of the right lower extremity with no neurologic
defect. Initial work up included a lower extremity ultrasound showing a hypoechoic, well-circumscribed,
avascular mass in the right lower leg anterior compartment with no evidence of deep vein thrombosis. A
subsequent MRI showed extensive peripheral edema within the right anterior compartment concerning
for compartment syndrome. Anterior compartment pressures were elevated at 100mmHg (normal
<30mmHg). The patient was taken emergently to the operating room where an anterior fasciotomy was
performed. Pathology from fasciotomy tissue showed acute necrotizing inflammation without mention
of leukemic infiltrate, and all tissue cultures were negative for bacterial or fungal growth. The patient
ultimately recovered, refused treatment for CMML and was discharged. He was re-admitted two
months later still with untreated CMML for right buttock pain and CT scan findings concerning for
hematoma vs. phlegmon. Drainage of the site was attempted however no fluid pocket was found. No
biopsy was performed as the patient ultimately chose to pursue comfort care and passed away within
several weeks.
This case illustrates the need for physicians to consider the diagnosis of compartment syndrome in
patients with leukemia presenting with severe limb pain. Although pathology did not confirm leukemic
cells within the muscle tissue, the patient had no other clear inciting factor therefore suggesting that
leukemic infiltration may have been the cause of his compartment syndrome. In addition, the patient
re-presented with muscle pain and imaging findings suggestive of muscle edema and fluid collection,
which may have been an early compartment syndrome. Compartment syndrome can be life threatening
therefore making early diagnosis and treatment essential.
Johnson, MD
Hantavirus Pulmonary Syndrome Causing Non-Cardiogenic Pulmonary Edema
Torie Johnson, MD, Jay Solnick, MD, PhD, Richart Harper, MD, Benjamin Durham,
Introduction: Hantavirus pulmonary syndrome (HPS) consists of anincubation period followed by a flulike prodrome, progressing to acardiopulmonary phase of variable severity. We present a case
ofHantavirus pulmonary syndrome causing non-cardiogenic pulmonaryedema.
Case: A 52 year-old man from northern California with a history ofhypertension went on a 3-week
summer vacation, first to Yosemite,then to Niagara Falls and finally to Yellowstone. Two nights
beforethe end of the trip he developed nausea. Over the next two days hedeveloped fevers, myalgias
and a headache, prompting him to presentto the emergency room upon his return home. He had an
unremarkableworkup other than mild thrombocytopenia with platelets 111,000. Hewas treated with
Tamiflu but continued to be symptomatic. Two dayslater he developed a cough and dyspnea. He visited
his primary careprovider and was treated for community acquired pneumonia withdoxycycline. Later
that day he became acutely dyspneic, complainingthat he had “water in his lungs” and returned to the
emergency room.He rapidly developed hypoxemic respiratory failure and was intubated.He was febrile
and hypotensive. Chest x-ray showed bilateral alveolarinfiltrates. Transthoracic echocardiogram showed
normal systolic anddiastolic function making hydrostatic edema an unlikely cause of hischest x-ray
findings. PaO2:FiO2 was <100 mmHg despite PEEP > 5 cmH20, consistent with severe ARDS. Labs
showed platelets 54,000,bandemia of 38%, hemoglobin 16.8, myelocytosis with atypicallymphocytes,
mild transaminitis, LDH 489, Na 128 and creatinine 1.5.He was started on empiric broad-spectrum
antibiotics with ventilatormanagement according to the ARDSNet protocol. HD 2 his AKI resolved.HD 3
norepinephrine was discontinued and he was aggressivelydiuresed. HD 4 his fevers subsided and
antibodies returned positivefor hantavirus Sin Nombre virus.
Discussion: Hantaviruses are RNA viruses in the familyBunyaviridae. Most cases of HPS in the U.S. affect
healthy adults andare attributed to the Sin Nombre virus. Transmission to humanstypically occurs via
inhalation of airborne virus particles excretedby deer mice. The clinical course is variable, with an
incubationperiod of up to 6 weeks followed by a viral prodrome lasting 3-5days. This may be followed by
a cardiopulmonary phase with abruptonset of cough and dyspnea, rapidly progressing to pulmonary
edema.HPS carries a case fatality rate of 36%, with most victims dyingwithin 48 hours of hospitalization.
This case illustrates thatalthough many victims of HPS present for evaluation during theprodromal
phase, the diagnosis is often elusive. HPS should besuspected in otherwise healthy patients with a
typical prodrome,known exposure risk and thrombocytopenia. Early recognition of HPSmay increase the
likelihood of survival. Ribavirin has in vitroactivity against hantaviruses but did not improve outcomes
inclinical trials.
An Association between Bevacizumab and Recurrent PosteriorReversible
Encephalopathy Syndrome (PRES) in a Patient Presentingwith Deep Vein
Thrombosis – A Case Report and Review of theLiterature
Mark A. Lazarus MD, Stanley Amundson MD, Rajesh Belani MD
Background: The posterior reversible encephalopathy syndrome(PRES) is a transient syndrome characterized by
hypertension,headache, seizures, and visual disturbances. Causes of PRES includepre-ecplampsia/eclampsia,
hypertension, immunosuppressive andchemotherapeutic agents, and recently bevacizumab, a
monoclonalantibody that specifically binds vascular endothelial growth factor(VEGF). Although reports of
recurrent PRES have increased recently inthe literature, to our knowledge there is no information about
PRESrecurrence in patients taking bevacizumab or descriptions of deepvein thrombosis (DVT) in the setting of
Case: A 72-year-old man with metastatic pulmonary adenocarcinomareceived maintenance bevacizumab following
six cycles of carboplatinand paclitaxel. Following his eighth dose of bevacizumab he wasdiagnosed with a DVT and
rapidly developed hypertension (164/75),myoclonus, tonic-clonic seizures and had bilateral upgoing
Babinskiresponses. Initial urinalysis revealed a protein level of 100 mg/dland a lumbar puncture revealed a total
protein level of 76 mg/dl.Brain magnetic resonance imaging demonstrated multiple smallbilateral cortical
hyperintensities involving the occipital lobes andcerebellar hemispheres consistent with leukoencephalopathy. By
dayfive the patient recovered and was alert, at his mental statusbaseline, and his blood pressure (BP) decreased to
134/69. He thendeveloped a fatal PRES recurrence nine days following his originalepisode.
Discussion: The near-simultaneous development of DVT and PRES wasdue to the anti-VEGF effect of bevacizumab.
VEGF inhibition causesDVT by enhancing subendothelial procoagulant phospholipids; reducingendothelial nitric
oxide production; and increasing proinflammatorycytokines expression. When coupled with an inappropriate
cerebrovascular accommodationvia damaged capillary endothelium, systemic protein extravasation andvasogenic
edema occur leading to PRES. Recurrence was secondary tobevacizumab’s ongoing anti-VEGF effect (half-life 11-50
days) despiteits discontinuation nine days earlier. The continued vasogenic edemacombined with suboptimal BP
management to an acute hypertensivecrisis likely resulted in recurrent PRES. This presentation is similar to preeclampsia whereby low serumVEGF and elevated levels of VEGF inhibitors, namely soluble FLT-1 andsoluble
endoglin (sEng), cause cerebral endothelial damage andsymptoms of PRES. Elevated serum levels of sVCAM-1, a
solubleadhesion molecule associated with leukocyte trafficking, have beenlinked to both preeclampsia and cancer
patients treated with VEGFinhibitor. Since both conditions share similar anti-angiogenesispathways, these soluble
factors conceivably reflect endothelialdysfunction in both processes.
Parallels between PRES and preeclampsia warrant furtherinvestigation as screening for hypertension, proteinuria,
andhyper-reflexia could be useful in analogous fashion to the currentstandard practice of monitoring pregnant
patients as these subtleclinical changes precede both syndromes. While measuring absolutelevels of sVCAM-1,
VEGF, sFlt-1 and sEng offers a promising approach;these tests are still considered experimental. Standard
screeningpractices would allow clinicians to identify early PRESmanifestations and discontinue the offending agent
while strictlycontrolling BP, ultimately reducing the likelihood of PRES.
Maarup, MD
A Fatal Course of Fever of Unknown Origin
Timothy J Maarup, MD Kaiser Permanente, Los Angeles Medical Center
Case Presentation: A 61 year old male with an 8 month history offever of unknown origin (FUO)
presents to the emergency department with 3 daysof painless jaundice. Previous workupfor FUO has
included tests for infectious, rheumatologic, and neoplasticsources, as well as liver and bone marrow
biopsies. Significant laboratoryfindings included a mild transaminitis and markedly elevated ferritin.On
this presentation he was notedto be afebrile, jaundiced and cachectic, but had no palpable
organomegaly.Admission workup was significant for WBC 12.0, ALT 2167, AST > 1000, andTbili 8.2
(direct bilirubin 5.2). Imaging studies revealed no obvious source ofacute hepatic failure. He developed
fever to 40C on hospital day (HD) 5 andthen became hypotensive on HD6 with a worsened leukocytosis.
Antibiotics andpressors were started on HD6 and 11, respectively. On HD12 he developed DIC,which was
treated supportively. He became anuric on HD17 and hemodialysis wasinitiated. He was then intubated
for respiratory distress on HD18. Given hisworsening clinical status, our hematologists repeated a bone
marrow biopsy with concern for hemophagocytic lymphohistiocytosis (HLH). Marrow
aspiratedemonstrated extensive hemophagocytosis. A soluble CD25 level was markedlyelevated.He was
started on dexamethasoneand etoposide on HD 20 without improvement. On HD25 he expired. The
patient’sfamily declined autopsy. Post-mortem, a chromosomal analysis of his marrowreturned positive
for rare deletions of chromosome 15.
Discussion: Herein we describe an unusual case of prolonged FUOlikely secondary to HLH.HLH is a rare
syndromecharacterized by fever, cytopenias, hyperferritinemia, and hemophagocytosis thatis rapidly
fatal if left untreated. It stems from a hyperstimulated, butineffective immune response and occurs in
both primary and secondary forms.Primary forms are associated with a variety of genetic defects that
lead topersistent hypercytokinemia through an impairment in apoptotic mechanisms. Theetiology of
secondary forms is less well understood, but seems to be due to apersistently activated immune
reaction in response to inadequate antigenclearance, neoplasm, or rheumatologic disease.The etiology
of HLH in ourpatient is unclear. Our FUO workup ruled out the most common precipitants ofsecondary
HLH. A chromosomal analysis performed on marrow cells demonstrateddeletions of chromosome 15.
Such deletions have been linked to primary HLH. Theproposed mechanism stems from a deficiency of
Rab27a, which leads to a defectin granzyme trafficking.We hypothesize that this patientsuffered from a
mid-life loss of heterozygosity leading to a late presentationof primary HLH. Idiopathic FUO is an unusual
presentation for HLH, with onlyabout 10 documented cases in the literature. These cases may represent
loss ofheterozygosity.
Nathaniel, MD
Amebic liver abscess presenting as aliver mass in Southern California
Brandon Nathaniel
Introduction: There are 40 to 50 million peopleinfected annually worldwide by amebiasis. Amebic liver
abscesses(ALA) are the most common extra-intestinal manifestation of Entamoebahistolytica infections.
This is commonly seen in endemic areas suchas: India, Mexico, Africa, and Asia. We describe a case of a
womanin Southern California with an ALA, presenting as a liver mass.
Case Presentation: A 45 year-old Hispanic female presentedwith a 5 day history of fever, abdominal
pain, and jaundice. Sheresides in Southern California and reported traveling to Mexico 5months prior.
Initial vital signs were: temperature 102.4, heartrate 98, blood pressure 103/67. Physical exam showed
anill-appearing female with jaundiced skin, scleral icterus andtenderness in the right upper quadrant
and hypogastrum. Cardiovascular, pulmonary, and neurologic exam were normal. Pertinentlab values
included: WBC 13.5 bill/L, 2.0% eosinophilia, Hgb 9.6g/dL, MCV 93.3, Cr 0.6 mg/dL, Alb 2.2 g/dL, ESR 103
mm/hr, ALT 158U/L, AST 87 U/L, Total Bilirubin 4.0 mg/dL, Direct Bilirubin 2.3mg/dL, Alk Phos 185 U/L,
and INR 1.3. Abdominal ultrasound showedpost-cholecystectomy changes but no focal masses. Based
on herinitial presentation, the differential diagnosis included viral orautoimmune hepatitis, cholangitis,
and other infectious processes. Empiric broad spectrum antibiotics were initiated. Hepatitis panel,ANA,
anti-smooth muscle, and anti-LKM antibodies were normal. Thepatient underwent a CT scan with
contrast demonstrating a 6.7 cmmultilobulated mass within the right lobe of the liver.
Radiologydifferential included hemangioma, liver mass, metastatic lesion orliver abscess, although the
mass appeared to be more solid. MRI withcontrast demonstrated a T1 hypointense, T2 hyperintense
periphery andhypointense T2 weighted center mass in the right liver lobe,measuring 8.1 x 7.1 x 7.1 cm.
Based on the MRI, the differentialincluded a peripheral cholangiocarcinoma, hepatic
metastasis,lymphoma, or hepatocellular carcinoma. Despite the imaging testssuggesting a solid mass,
we had suspicions of an infectious process. Entamoeba histolytica antibodies were sent and the patient
was setupfor CT guided biopsy/aspiration of the mass. When the needle wasplaced into the mass,
purulent material was aspirated with anchovypaste appearance which cultured negative. Serum E.
histolyticaantibodies later returned positive, confirming the diagnosis. Antibiotics were changed to
Flagyl followed by a course ofparomomycin.
Discussion: ALA is a disease more commonly seen inimmigrants or travelers to endemic areas. Our case
demonstrates thatdespite radiological concerns for a solid liver mass, the clinicalpicture was that of
infection. A careful history including detailssuch as recent travel is imperative. This case highlights that
ALAshould be in the differential for RUQ abdominal pain and fevers evenin the US.
In the Blink of an Eye: Rapid Progression of Syphilis in a Patient with HIV
First Author: Allison K Nitsch, MD Second Author: Joseph R Sweigart, MD
Introduction: Syphilis is a sexually transmitted disease caused by spirochete Treponema pallidum.
Syphilis has recently resurged and can present unpredictably in human immunodeficiency virus (HIV)
positive patients.
Case Presentation: A 28 year-old man presented with headache and abnormal vision. A skin rash had
begun 9 months prior. He had not noticed genital ulcerations but was having right testicular swelling. He
was diagnosed with HIV on routine screening. He reported prior anaphylaxis to penicillin. His only
medications were non-prescription eye drops.
His left pupil was irregular and did not react to light or accommodate. He had a left infratemporal visual
field deficit. Cataracts prevented fundoscopy. Skin was lichenified with hyperpigmented plaques and
scattered erythematous macules localized to his palms and soles. Patellar reflexes were hyperactive
bilaterally with decreased proprioception. His gait was so severely ataxic that he required a walker . His
right testis had a firm nodule on the posterior aspect with unilateral inguinal lymphadenopathy.
Hematology, chemistry, and hepatic profiles were within normal limits. CD4 count was 490 and
quantitative HIV polymerase chain reaction was 1,720,000. Cerebrospinal fluid (CSF) studies
demonstrated 303 nucleated cells, 9% neutrophils and 90% lymphocytes. His right testicle had a
circumscribed testicular lesion of soft tissue density by ultrasound. Serum RPR resulted as >1:256 and
FTA-ABS was positive. CSF VDRL was reactive with a titer of 1:4. Based on his rash, visual changes, ataxia,
and testicular gumma, he was diagnosed with simultaneous secondary and tertiary syphilis. He was
treated for neurosyphilis with penicillin desensitization.
Discussion: General internists must be aware that syphilis can present atypically. The chancre, the
marker of primary syphilis, occurs within ninety days of exposure. Secondary syphilis can include
condylomata lata or generalized maculopapular rash one to three months after exposure. Rates of
primary and secondary syphilis
increased from 2.1 to 3.8 cases per 100,000 persons from 2001 to 2008. Tertiary syphilis can manifest
months to years after exposure and may include neurologic, cardiovascular, or gummatous syphilis.
Neurospyhilis results from treponemal entry into the CSF and can cause sensory ataxia, called tabes
dorsalis, via changes in posterior columns. Neurospyhilis can occur at any stage of infection. HIV positive
persons are at increased risk. Symptomatic early neurospyhilis is a rare presentation, occurring within
twelve months of exposure in approximately 1.7% of syphilis infections. Ataxia is present in just 4% of
such cases. Signs of simultaneous secondary infection at the time of initial diagnosis of early
neurosyphilis are present in only 10% of cases. First line treatment of neurosyphilis is IV penicillin G.
Non-penicillin regimens are indicated only if penicillin or desensitization fails.
Topical Tacrolimus-Associated Eczema Herpeticum Exacerbated by
Prednisone – A Case Report
First Author: Brian Petersen, MD Second Author: Christopher Slater, MD
CASE PRESENTATION: A 37-year-old female with a life-long history of eczema, treated with topical
tacrolimus daily and intermittent clobetasol for flares, presented with an evolving skin eruption. The
rash began as painful red lesions on the left wrist, spreading to her hands, associated with fever and
chills. She was seen at her primary care office three days before admission and was prescribed
prednisone 40 mg daily, with tapering doses for one week. The following day, the patient’s pain had
increased and the skin eruption had spread from her hands to her inner thighs, torso, neck and face. She
came to our hospital for further evaluation.
HOSPITAL COURSE: On admission, the patient had extensive, 1-2 mm, punched-out erosions with
eschars, and rare vesicles on an erythematous base, most concentrated on the dorsal and palmer
aspects of her hands (figures 1 and 2, respectively). The lesions were also present on her inner thighs,
neck, face, and upper chest; no mucosal or genital lesions were present. The patient denied a history of
herpes infection, but her husband had a remote history of “cold sores”. The patient was diagnosed with
eczema herpeticum, which was confirmed by viral culture. She was treated with intravenous acyclovir
for HSV-1 and had improvement of her symptoms.
DISCUSSION: Eczema herpeticum is a disseminated form of herpes simplex virus that complicates atopic
dermatitis. Topical tacrolimus, which is used as an alternative to corticosteroids in patients with eczema,
has an inhibitory effect on cytokine production, and suppresses cellular immunity by inhibiting Tlymphocyte activation. Its use has been associated with an increased risk of eczema herpeticum. The
initiation of prednisone further suppressed this patient’s cellular immunity, worsening the infection.
Intravenous acyclovir is the treatment of choice for eczema herpeticum, and should be initiated as soon
as the diagnosis is suspected.
CONCLUSION: Providers need to be aware of the complications of atopic dermatitis, especially eczema
herpeticum, and be cautious in prescribing oral steroids to patients who are already using topical
First Author: Ben R Mendoza, III MD Second author: Livia Tsien MS4 Third author: Michael Morton MD
Case Presentation: Mr. B is a 61 year old male who presented with recurrent palpitations and syncope.
The patient had previously been in good health and had been a marathon runner until three years prior
to admission. He had stopped running due to decreased exercise tolerance, fatigue, and worsening
dyspnea with exertion. Over the past two years, he experienced rare palpitations and near-syncope.
Recently, he restarted running for exercise, but was limited by poor exercise tolerance. A week prior to
admission, the patient experienced recurrent palpitations followed by syncope. He was admitted to an
outside hospital where a thallium stress test showed no evidence of stress-induced ischemia. CT
angiography of the chest noted moderate enlargement of mediastinal lymph nodes and a few small
pulmonary nodules. After discharge, he had recurrent self-limiting palpitations, and was admitted to our
hospital for evaluation. During an episode of palpitations, telemetry demonstrated sustained,
monomorphic ventricular tachycardia with a heart rate of 280 bpm. The QRS morphology was left
bundle-like with a superior axis and transition in lead V2, suggesting the focus was originating from the
RV or LV septum. The patient remained awake, and the VT lasted approximately three minutes before
spontaneously converting back to sinus rhythm. Given his arrhythmia and known lymph node
enlargements, a cardiac MRI was performed to evaluate for evidence of an infiltrative process such as
sarcoidosis versus arrhythmogenic right ventricular dysplasia (ARVD). Cardiac MRI was consistent with
an infiltrative process; therefore, a transbronchial biopsy of the mediastinal lymph nodes was
performed. Pathology showed granulomatous disease, consistent with sarcoidosis. The patient was
begun on systemic therapy with methotrexate and prednisone.
Discussion: Sarcoidosis is a chronic granulomatous disease of unclear etiology that affects nearly any
organ. The prevalence of sarcoidosis in the US has been estimated between 5 and 35 per 100,000, and is
3 to 4 times more common in African-Americans compared to Caucasians. Sarcoidosis most commonly
presents prior to the fourth decade of life as pulmonary, skin, or eye manifestations. In known cases of
sarcoidosis, estimates of cardiac involvement range between 20% and 30% based on cadaveric studies.
The clinical presentation of cardiac sarcoidosis (CS) ranges from asymptomatic conduction abnormalities
to congestive heart failure and sudden death from ventricular arrhythmias. Complications from CS
account for death from sarcoidosis in 13% to 50% of cases; however, only 40% to 50% of patients with
CS proven by necropsy had clinical manifestations. The relationship between CS and systemic sarcoidosis
is unclear in that autopsy studies suggest that patients with CS have minimal extra-cardiac symptoms.
These observations, along with lack of sensitivity of known diagnostic modalities make the diagnosis of
CS difficult. In patients with no prior history of sarcoidosis symptoms it is important to consider CS as a
cause of sustained ventricular tachycardia. In patients with a history of sarcoidosis, it is not only
important to understand the lack of effective screening, but also the dangers CS may pose.
An uncommon route for an uncommon pathogen
First Author: Brittany R. Folks, MD Second Author: Michael T. Morton, MD, FACP
Introduction: Mycobacterium bovis is the causative agent of tuberculosis in cattle and other mammals;
however, it may also infect humans. The most common routes of transmission include ingestion of
unpasteurized milk and contact with aerosolized particles, but other routes are potentially possible.
Case Presentation: An 81 year old gentleman with type 2 diabetes mellitus, coronary artery disease, and
osteoarthritis recently returned from his ranch in Mexico with worsening joint pain, fever, cough, and
somnolence. Upon admission, he was found to have bilateral infiltrates on chest x-ray and treated for
community-acquired pneumonia. Despite antibiotic therapy, he remained febrile with temperatures as
high as 105°F. He was also noted to have worsening inflammation and effusion of his knee joints.
Routine blood cultures and serologies for Mycoplasma, HIV, Brucella, Coxiella, Coccidioides, Francisella,
Leptospira, Yersinia, and Hantavirus were negative, as were an ANA and ANCA. His quantiferon was
elevated, but three sputum AFB smears were negative. He remained febrile despite the addition of
antifungals. Lumbar puncture, knee arthrocentesis, and bone marrow biopsy were performed and
initially unremarkable. Within several days, he required intubation for respiratory decompensation.
Bronchoscopy was performed, and washings returned positive for acid-fast bacilli. He was placed on
quadruple therapy with Ethambutol, Isoniazid, Rifampin, and Levofloxacin. Acid-fast bacilli also
eventually grew from his bone marrow. Family later reported that while in Mexico, he had been selfadministering intraarticular steroid injections for his osteoarthritis with needles also used on cattle. He
demonstrated improvement throughout the next several weeks and was eventually discharged. Final
speciation at six weeks returned M. bovis.
Discussion: Mycobacterium bovis accounts for only 1-2% of human tuberculosis cases in the US but may
be implicated in up to 10-15% of cases in developing countries. M. bovis should be considered in
patients from endemic areas, Hispanics, age less than 15 years, immunosuppressed or HIV positive
individuals, or those with manifestations of extrapulmonary disease. Typical routes of infection include
unpasteurized dairy products and direct contact with infected cattle, elk, deer, and other mammals. We
hypothesize that this patient acquired his infection through needle inoculation and subsequent
hematologic spread, which, to our knowledge, has not previously been described. M. bovis is more likely
than M. tuberculosis to involve lymph nodes, the GI/GU tracts, joints, soft tissues, the CNS, and other
extrapulmonary sites. M. bovis is also associated with a greater than two-fold increase in mortality.
Otherwise, the two diseases are largely clinically and radiographically indistinguishable, and the same
tests are used in diagnosis. M. bovis is inherently resistant to Pyrazinamide, so empiric therapy with
Isoniazid, Rifampin, and Ethambutol should be initiated and continued for two months followed
by seven months of Isoniazid and Rifampin.
Pseudohypobicarbonatemia, A False Truth About Acidemia.
First Author: Christopher Slater, MD Second Author: Michael Benoit, MD Third Author: Aaron Calderon,
Introduction: Causes of metabolic acidosis with a normal arterial blood gas and osmolar gap are
uncommon and only supported by case reports in the medical literature. We present a case of a patient
who was admitted to the intensive care unit for presumed severe acidosis by direct serum carbon
dioxide and anion gap measurements but normal pH and bicarbonate by serum gas calculation.Case
Case Presentation:: A 47 year old male with a past medical history significant for cirrhosis due to
alcoholic liver disease, obesity and pre-diabetes initially presented to the emergency department for
severe depression. Surprisingly, laboratory evaluation revealed a carbon dioxide of 9 mEq/L and a high
anion gap of 26 mEq/L suggestive of metabolic acidosis. His lactate returned at 2.5 mmol/L and his
urine was positive for benzodiazepines and small ketones. His salicylate level returned normal, in
addition to his serum osmolar gap. Follow up ABG at the time of admission showed a high-normal pH of
7.44 with a calculated bicarbonate level within the normal limits at 23 mEq/L. After correcting for his
initial elevation in lactate and slight ketosis presumed secondary from dehydration, diabetic
ketoacidosis and starvation, multiple subsequent venous bicarbonate levels continued to range from 714 mEq/L with a high anion gap ranging from 18-26 mEq/L. Each venous sample was noted to have
lipemic interference by the laboratory, however, a fasting lipid panel showed the following: Total
Cholesterol 215, Triglycerides 151, HDL 53, LDL 132. Of note, his protein level was normal at 6.8 g/dL
and the result of serum protein electrophoresis is pending at the time of this abstract. Previous labs
from 2010 and 2005 revealed a normal albumin and SPEP, respectively.
Discussion: This case illustrates our dependence and bias for direct measurements of serum carbon
dioxide in contrast to calculated ABG bicarbonate levels in determining metabolic acidosis. In addition,
the initial evaluation of metabolic acidosis in this patient exposes how easily one can misdiagnose and
deliver incorrect and harmful treatment, particularly if laboratory studies are not clinically correlated.
Clinicians should be aware that our current methods for determining serum acidosis can be flawed by
potential lab interference but causality remains unclear in our case with normal lipids and protein levels.
Armed with this information, medical providers can prevent future unnecessary admissions, undue
costs, and deliver appropriate patient care. Our case is significant in that, to the best of our knowledge,
this is only the second case of psueohypobicarbonatemia in the medical literature.
Telaprevir Induced Urate Nephropathy
First Author: David Johansen, MD Second Author: Zachary Hesse, MD Third Author: Michael Morton, MD
Case Presentation: Mr. J is a 59 year old male with a history of hypertension and hepatitis C, genotype
1b. A liver biopsy in 2004 using the Metavir staging system showed hepatitis stage 2, and fibrosis stage
1. The patient underwent treatment with peginterferon and ribavirin in 2006. He tolerated 12 weeks of
treatment but failed to have a 2-log decrease in viral loads. Therapy was discontinued. In 2012 he
approached his gastroenterologist requesting treatment with the new medicine for hepatitis C. Baseline
laboratory work showed hepatitis C viral load 6.5 log copies, AST 171, ALT 243, with other lab results
normal, but notable for a creatinine of 0.8 and uric acid of 5.8. He initiated triple therapy with
peginterferon, ribavirin and telaprevir. Five days after starting treatment, repeat labs were drawn. The
lab tests were abnormal for a creatinine of 3.8 and a uric acid of 18.3. The remaining lab results were
largely unchanged. Triple therapy was discontinued and he was admitted to the hospital. He admitted to
fatigue, nausea and two episodes of emesis. He denied decreased oral intake or decreased urine
output, and the rest of the review of systems was likewise negative. Home medications included
losartan 50mg daily, triamterene-hydrochlorothiazide 37.5/25 mg daily, metoprolol tartrate 12.5 mg
twice daily, and meloxicam 15 mg daily. Nephrology was consulted for acute urate nephropathy. He was
treated with emergent hemodialysis. He tolerated therapy well and was discharged home after two
nights in the hospital. Follow up lab results a week after the admission showed a creatinine of 1.3 and
uric acid of 7.7. His symptoms of fatigue and nausea resolved.
Discussion: Chronic hepatitis C infection affects 2.7-3.9 million people in the United States. Most
individuals are unaware they are infected. The CDC has recently recommended one time screening for
hepatitis C in all individuals born between 1945 and 1965. As more individuals become aware of their
infection through screening, more will desire treatment. Fortunately, there are multiple different drug
classes under development for treatment of hepatitis C with the protease inhibitors telaprevir and
boceprevir being recently approved. The American Association for the Study of Liver Diseases changed
their treatment of hepatitis C guidelines to include a protease inhibitor in addition to the previously
recommended regimen of peginterferon and ribavirin. The addition of telaprevir increases sustained
viral response rate from 44% to 75%. With any new therapy there will be adverse events and side
effects. During clinical trials, telaprevir was most frequently associated with rash and anemia that at
times forced discontinuation of therapy. In addition, telaprevir is known to cause hyperuricemia in up to
73% of patients, with levels greater than 12.1 in 7% of patients. Despite elevated uric acid levels, less
than 1% of patients experienced gout, and none experienced urate acid induced nephropathy. As
treatment with telaprevir becomes more common, it is important to be aware of its adverse effect
profile, and that urate acid nephropathy can occur after only 5 days of therapy.
Ataxia, Headache and Altered Mental Status: a case of neuro Behcet's
First Author: Jennifer Y Wu, MD, Jodie Barr, DO, Michael Fisher, MD, Robert Gibbons, MD
Introduction: Headache and altered mental status require a broad differential. Our case of neuro
Behcet's disease, parenchymal neuro variant, presented with headache, cerebellar signs, and altered
mental status, but had delayed diagnosis.
Case: Ms. G is a 34 year old African American female who presented with altered mental status, ataxia,
bizarre behavior, and severe headache. Three months prior, she was admitted to an outside hospital
with similar symptoms, and underwent an extensive infectious disease workup including three lumbar
punctures which showed WBC 856, RBC 22, Polys 65, Lymphocytes 23, Monos 12, Glucose 49, and
Protein 90. Studies including; VZV, HSV, CMV, EBV, TB PCR, HIV, Lyme, VDRL, bartonella, and ACEi level
were negative. The only positive studies were an ANA of 1:180 and toxo IgG. MRI showed unusual
lesions with a small focus of enhancement in the medulla and pons. She improved with antibacterials,
acyclovir, and dexamethasone, and was discharged.
She represented with recurrent symptoms and was started on acyclovir, vancomycin, ceftriaxone, and
dexamethasone. MRI and CT head showed progression of hyperintense signal changes through the
brainstem and cerebrum. A repeat viral workup proved negative along with universal fungal, bacterial,
AFB PCRs and flow cytometry. Rheumatology proposed neuro Behcet's with the patient's history of oral
and genital ulcers and an outpatient diagnosis of papillitis. Her symptoms resolved on discharge;
however, a pending TB quantiferon result (later negative) prevented discharge on steroids.
She was readmitted with recurring symptoms and started only on high dose IV solumedrol with
improvement. MRI showed worsening abnormal signal at the left thalamus and internal capsule, with
new areas of enhancement at the pons and diencephalon considered consistent with Behcet’s. Given
her negative infectious disease workup, improvement on steroids alone, ulcers and vision complaints,
and family history of autoimmune disease, she was diagnosed with Behcet's and discharged on high
dose oral prednisone.
Discussion: Behcet's disease is a rare, immune-mediated systemic disease that presents with mucus
membrane ulcers, ocular problems, and uveitis. It can also involve the gastrointestinal tract, pulmonary,
musculoskeletal, cardiovascular and neurological systems.
Neuro Behcet’s appears in 5-30% of patients and has two different, distinct presentations: parenchymal
and non-parenchymal. Parenchymal neuro Behcet’s can present with cognitive changes, hemiparesis,
and fevers, as well as pyramidal tract and brain stem signs. There may be a relapsing/remitting course or
progressive course after the first acute attack. On MRI, lesions are predominantly located in the
brainstem, thalami and basal ganglia. However, it can also involve the cerebral hemispheres,
cerebellum, spinal cord, and other sites. In our patient, her lesions were primarily in the medulla and
pons, consistent with parenchymal neuro Behcet's. Patients are treated with azathioprine,
methotrexate, and steroids, or a combination of the three.
Our patient illustrates the importance of considering a broad differential when addressing the symptom
complex of headache and altered mental status.
Apical Hypertrophic Cardiomyopathy, a BENIGN Form of Heart Disease?
First Author: Hannah Hall, MD¹, Maria Frank, MD² University of Colorado, Internal Medicine Residency
Program¹ Hospital Medicine, Denver Health and Hospital Authority²
Introduction: Apical hypertrophic cardiomyopathy (AHCM) is a subtype of hypertrophic
cardiomyopathy first described as a benign disease in Japan. The risk of sudden cardiac death in AHCM is
thought to be lower than classic hypertrophic cardiomyopathy. However, recent cases in the literature
report adverse outcomes in AHCM, especially in the non-Asian population. We present a patient with
ventricular fibrillation (VF) arrest secondary to AHCM which raises the question of whether further
intervention and monitoring is necessary.
Case Presentation: A fifty-two year old Hispanic male with history of epilepsy and untreated diabetes
presented with VF arrest followed by return of spontaneous circulation. His exam was significant for a
systolic murmur and amnesia post-event. There was no family history of sudden cardiac death. Initial
EKG showed ST elevations without evidence of significant coronary artery disease on cardiac
catheterization. Troponins peaked at 594. Subsequent EKGs revealed prominent T wave inversions in
the anterolateral leads. Transthoracic echo (TTE) showed apical hypertrophy, akinesis, and thrombus.
MRI revealed left ventricular AHCM with the “ace-of-spades” sign at end diastole, apical thrombus with
edema and scar consistent with myocardial infarction due to subendocardial hypoperfusion. An
automatic implantable cardioverter defibrillator was placed before discharge.
Discussion: AHCM was first described in Japanese patients with left ventricular apical hypertrophy with
wall thickness of 15mm and above, giant negative T waves in the precordial leads and a spade-like
configuration of the LV at end-diastole. The prevalence of AHCM is 15% in Japan vs. 3% in the US. One
Canadian retrospective study of 105 patients with AHCM found 0.1% annual mortality, with 30%
experiencing morbid events (12% atrial fibrillation, 10 % myocardial infarction). They concluded AHCM
has a benign prognosis and not a risk for cardiac death. However, there have been multiple reports of
supraventricular tachycardia, sustained monomorphic ventricular tachycardia, VF and myocardial
ischemia. A 3-year prospective South Korean observational study with 454 AHCM patients showed an
all-cause mortality of 9% with 5% cardiovascular mortality.
Conclusion: Our case illustrates the need for further research to address clinical predictors and
guidelines for the management of AHCM, where adverse clinical events seem to be more prevalent than
previously considered.
"Whole Body Rash: Differential Diagnosis on a 'Large Scale'"
DAVID THEIS, D.O., ACP Internal Medicine Resident, PGY-3 Exempla Saint Joseph Hospital, Denver, CO
Case Presentation: A 57-year-old African American femalepresented to the hospital with skin lesions
covering her entire body. Lesions began on her neck three months prior, andspread to her trunk,
extremities, and face, relatively sparing the palms andsoles. Six weeks prior tohospitalization, she had
been evaluated at a dermatology clinic and wasdiagnosed with hyperkeratosis. She was startedon
prednisone, cephalexin, acyclovir, and hydroxyzine with no improvement in thelesions. She had picked
off parts of thelesions on her face without pain or bleeding, and the lesions slowly grew back. The
patient lived in Colorado and Utah herwhole life, denied travel outside of the U.S., and had no fevers,
sweats, or weightloss. Two months prior to admission (onemonth after lesions began), she did suffer a
non-traumatic proximal humerusfracture, and subsequent bone scan showed a lesion at the fracture
site. Medical history: hypertension. Medications: hydroxyzine and citalopram.Social: lifetime nonsmoker, no alcohol or drug use; single, no sexualactivity, lives with sister.Labs on admission revealed
creatinine 2.0, albumin3.1, alkaline phosphatase 429, hemoglobin 8.7, urinalysis with +protein. Wound
culture from a lesion on the face grewmany pseudomonas aeruginosa and fewenterococcus species.
Wound cultures foracid fast bacilli, fungus, and parasite studies were negative, and bloodcultures were
negative. Skin biopsiesrevealed hyperkeratosis with spicules. Urineprotein electrophoresis showed a
Kappa light chain spike in the urine. The patient was diagnosed with multiplemyeloma-associated
follicular hyperkeratosis with spicules—a rare skinmanifestation of myeloma. Bacterialwound cultures
were felt to be only superficial skin colonization andantibiotics were not administered. Chemotherapy
with bortezomib was initiated and patient was dischargedfor regular follow-up for continued
chemotherapy. Over the next year, the patient’s skinlesions gradually improved. Lesions thenrecurred,
and SPEP revealed recurrence of myeloma, and she underwent autologous bone marrow transplant,
with improvement of her lesions again noted. Hence her lesions were foundto be a marker for disease
activity.Discussion: Numerousmalignancies have been associated with dermatologic conditions, some of
whichare paraneoplastic. Our patientpresented with a rare manifestation, follicular hyperkeratosis with
spiculesassociated with multiple myeloma (FHSMM). This skin eruption heralded the diagnosis of
multiple myeloma and thepatient’s subsequent need for hospitalization, and also posed
multipleinpatient challenges for diagnosis and management of opportunistic skininfections while
initiating chemotherapy. Literature search revealed few cases of FHSMM, and descriptions all wereof a
less dramatic presentation. Itremains unclear whether these lesions portend a worse prognosis for
multiplemyeloma, and treatment of the myeloma has resulted in improvement and oftenresolution of
the lesions.Conclusions:Thepurpose of reporting this case is to increase general awareness of this
rarecondition and to provide an up-to-date literature review.
Waiting For a Liver and Smoking Marijuana: Stuck in the Weeds.
First Author: Megan S Lemay, MD Second: Jeanette Tetrault, MD Third: William Becker, MD
Introduction: Over 16,000 people are awaiting liver transplantation in the US. Currently, 18 states have
legislation legalizing the use of medical marijuana, and two states recently voted to legalize the
recreational use of marijuana. This makes it increasingly likely that transplant programs will be
evaluating patients who use marijuana.
Case Presentation: MG was a 47 year old man suffering from decompensated cirrhosis secondary to
Primary Sclerosing Cholangitis. Mr. G was admitted to the inpatient liver service in August 2011 with
nausea and altered mental status. A urinary toxicology on admission was positive for cannabinoids, and
he reported non-medical marijuana use three times weekly. He denied other illicit substances and his
last reported use of alcohol was in 2008. Exam was notable for grade 2 encephalopathy, jaundice, and
tense ascites. His Model for End-Stage Liver Disease (MELD) score was 22. MG’s case was discussed at
the Recipient Review Committee for Liver Transplantation. It was determined that MG would need to
complete six months of rehabilitation for illicit marijuana use and document negative urine toxicology
before being considered for transplantation. In the next two months, MG developed further
complications of cirrhosis including variceal bleeding, worsening encephalopathy, and hepatorenal
syndrome. Following his family’s decision to withdraw medical care, MG died in November, 2011. His
MELD score at the time of his death was 50. Controversy surrounds whether marijuana use should
impact transplantation listing. On one hand, there are no data suggesting worse outcomes among
marijuana users undergoing liver transplantation. In one retrospective cohort study of patients with
chronic liver disease being considered for transplantation, there was no difference in mortality between
marijuana-smokers and non-marijuana smokers [1]. The authors concluded that current policies
regarding marijuana use may expose these patients to an increased risk of mortality.
Additionally, marijuana use has been shown to improve symptoms often experienced by patients with
end stage liver disease, such as dysphoric mood and nausea [2]. Cannabinoids also have in-vitro antiinflammatory effects which may aid in immune-suppression after transplantation as well as decrease
oxidative stress leading to ischemia/reperfusion injury post-operatively [3]. On the other hand, cannabis
use is correlated with use of other illicit drugs and alcohol [5]. Additionally, although adverse effects of
smoking marijuana may not be equivalent to cigarette smoking, there is evidence of increased morbidity
and mortality among post-transplant cigarette smokers [4]. Overall, no evidence exists that illicit or
medical marijuana use has a negative impact on patients with chronic liver disease being considered for
transplantation. As marijuana becomes increasingly legally available, consideration should be given to
whether marijuana use should contraindicate or delay transplant listing.
Primary References:
3. 1. Ranney, D. N., W. B. Acker, S. N. Al-Holou, L. Ehrlichman, D. S. Lee, S. A. Lewin, C. Nguyen, S. F. Peterson, K. Sell, J. Kubus, D. Reid, and M.
J. Englesbe. "Marijuana Use in Potential Liver Transplant Candidates." American Journal of Transplantation 9.2 (2009): 280-85. Print.
4. 2. Alexander, Amy, Paul F. Smith, and Rhonda J. Rosengren. "Cannabinoids in the Treatment of Cancer." Cancer Letters 285.1 (2009): 6-12.
5. 3. Nagarkatti, Mitzi, Sadiye Amcaoglu Rieder, Venkatesh L. Hegde, Shunsuke Kanada, and Prakash Nagarkatti. "Do Cannabinoids Have a
Therapeutic Role in Transplantation?" Trends in Pharmacological Sciences 31.8 (2010): 345-50. Print.
6. 4. Bright, Robert P. "Denial of Hepatic Transplantation on the Basis of Smoking: Is It Ethical?" Current Opinion in Organ Transplantation
15.2 (2010): 249-53. Print.
7. 5. Hall, Wayne, and Louisa Degenhardt. "Adverse Health Effects of Non-medical Cannabis Use." The Lancet 374.9698 (2009): 1383-391. Print
Hemophagocytic Lymphohistiocytosis: A Diagnostic and Therapeutic Dilemma
in the Critical Care Setting
First Author: Ranjit Joseph, MD Second Author:Shine Raju, MD Third Author: Anupam Kumar,MD Fourth
Author: Praveen Joseph, MD Fifth Author: Maria Gorgan, MD Sixth Author: John McArdle, MD
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal condition
resulting from hyperinflammation and profound immune dysregulation. It can be genetic or acquired
and is usually treated with corticosteroids, immunomodulators and chemotherapy. Here we describe a
patient with HLH in the critical care setting who responded to corticosteroid therapy alone.
Case Presentation: A 48 year-old woman with a history of hypertension presented with complaints of
malaise, fevers, diarrhea and a spreading rash for one week after a trip to Las Vegas with friends; many
of whom also developed diarrhea, but which was self-limited. The exam was significant for a
temperature of 99.8 F, BP 94/52 mmHg, and a generalized erythematous rash.
Her creatinine was initially 6.3 mg/dL, progressing to 11 mg/dL by hospital day 4 (D4) requiring
hemodialysis. The hemoglobin and hematocrit dropped from 12.1 mg/dL and 34.2 % to 7.2 mg/dL and
20.1 %, respectively. She developed a generalized seizure and was intubated for airway protection.
Transaminitis was present and she subsequently became hypotensive requiring pressors, but cultures
remained negative. Platelets dropped from 234 x109/L on D3 to 24 x109/L on D8. Stool studies for ova,
parasites and bacterial infections were negative, as were EBV and CMV serologies Considering the
clinical picture of multi-organ failure (MOF), the possibility of HLH was entertained and the she was
placed on pulse dose steroids with methylprednisone; a bone marrow biopsy and aspirate confirmed
this diagnosis (Figure 1). Additional findings included marked elevation of ferritin (4,873 µg/L). She was
subsequently transitioned to a slow taper of methylprednisone with marked improvement on discharge
(Figure 2).
Discussion: Although not specific for HLH, hemophagocytic histiocytes have been demonstrated in onethird of patients who die in the intensive care unit, particularly in association with MOF. Thus, there may
be cases of HLH going undiagnosed, and with greater awareness of this condition and early therapy
more lives may be saved. According to the HLH-2004 protocol, initial treatment includes
dexamethasone, cyclosporine, and etoposide. However, these agents may not always be appropriate in
the critical care environment. In the setting of suspected septic shock or MOF it can be unnerving to
start such patients on immunosuppresants. This is what made our case such a diagnostic and
therapeutic dilemma. Additional studies are required to determine the effects of methylprednisone
alone on long term mortality in HLH as well as the safety profile of cyclospine and etoposide in MOF.
Leonine Facies in a Man with Recurrent T-Cell Large Granulocytic Leukemia
First Author: Fady Hannah-Shmouni, MD Second Author: Robert J. Nardino, MD
Introduction: T- Cell Large Granulocytic Leukemia (T-LGL) is a relatively rare, malignant blood disease of
the mature T-cells of unknown etiology. No report on the occurrence of diffuse lesions in patients with
T-LGL exists in the medical literature.
Case Presentation:: A 58-year-old, African American man with leonine facies and history of stable and
long term T-LGL (on maintenance therapy with granulocyte colony-stimulating factor, Filgrastim
(Neupogen) and Epoetin Alpha (Procrit) for pancytopenia), and active HCV on antiviral therapy (including
interferon therapy), presented to the ED with the complaint of slow-onset, diffuse and mildly pruritic
skin lesions that first appeared in the forearms. These lesions had manifested 2 weeks earlier that
prompted the patient to voluntarily increase utilization of growth factor therapy and discontinue HCV
therapy. Clinical examination revealed diffuse and symmetrical nodular indurations of various sizes with
urticarial plaques, mostly pronounced on the forearms, and swelling of the face and hands causing
restricted movement. His medical history revealed that he had not been feeling well for the past week,
had experienced significant weight loss (15 kg in 3 weeks), with recurrent vomiting and diarrhea.
Additional physical examination did not show other abnormalities. The cutaneous lesions and the
history raised the suspicion of recurrence of his underlying malignancy, drug hypersensitivity reaction,
scleromyxedema secondary to interferon therapy or a variant of Sweet’s syndrome. Laboratory
screening and skin biopsy were performed to narrow the differential.
Biochemical evaluation showed an elevated WBC (23.4, normal 4.3-10.8 x 109 cells per liter) with
lymphocytosis (58.9%) that consisted predominantly of large granular-type lymphocytes. The
hemoglobin concentration was 8.3 mmol/l (normal 8.2–11.0) with thrombocytopenia 49x109 per liter
(normal 150-400 x 109 per liter). The total protein was low 5.4 gm/ml (normal 6.5-8.0 gm/ml). Testing
for antinuclear antibodies was negative and evidence of acute kidney injury was observed. HCV viral
load was undetectable.
Histopathological examination showed a patchy moderate perivascular and interstitial, superficial and
mild dermal infiltrate composed predominantly of variably sized lymphocytes and histiocytes with upper
dermal edema. The cells stained positive for CD5 and CD3. Significant CD56, CD57 and CD2 expression
was not observed. The ratio of CD4+/CD8+ was 1:1. Based on the clinical presentation, laboratory data
and histopathological examination, we made the diagnosis of recurrent T-LGL with skin involvement.
The patient, however, left AMA with subsequent loss to follow-up.
Discussion: This case illustrates the potential for T-LGL to present with diffuse skin lesions and Leonine
facies that may be initially mistaken for an alternate diagnosis, such as a drug hypersensitivity reaction,
Sweet's syndrome or Scleromyxedema. Albeit a rare occurrence or recurrence, it is important for
clinicians to know that leukemia’s can present with diffuse skin lesions that could ultimately restrict
bodily movements, as demonstrated in this case report.
Acute Aortic Thrombus With Distal Limb Ischemia As The Initial Presentation
Of Acute Myelogenous Leukemia
First Author: Shine Raju, MD S. Khalid, MD R. Joseph, MD S. Mirza, MD A. Kumar, MD E. Salerno, MD
INTRODUCTION: An acute aortic thrombus is an uncommon entity, mostly secondary to trauma or
atherosclerosis. We describe a case of acute infra-renal aortic thrombus with distal limb ischemia as the
initial presentation of acute myelogenous leukemia (AML).
Case Presentation: A 63-year-old female presented with a one-day history of sudden right lower
extremity pain and ‘blue toes’. Past history was notable for a 40 pack-year smoking history and
hypertension. On examination, she had cyanosis of her right toes and absent dorsalis pedis and
posterior tibial pulses with feeble pulses in the right femoral artery. Laboratory examination revealed
anemia, leucocytosis and thrombocytopenia with a D-dimer of 16108, fibrinogen of 125 and an INR of
1.6. Computerized tomography (CT) angiogram revealed near-complete occlusion of the infrarenal
abdominal aorta with reconstitution of the bilateral common iliac arteries just distal to the occlusion.
Her disseminated intravascular coagulation (DIC) was aggressively corrected and a transfemoral aortic
embolectomy was done with successful reperfusion. A bone marrow biopsy was subsequently done,
which showed greater than 20% blasts confirming the diagnosis of AML. Her hospital course was
complicated by severe neutropenia and sepsis after chemotherapy and she expired on day 29 of
DISCUSSION: Acute aortic thrombosis is usually a result of trauma, atherosclerotic disease or secondary
to hypercoaguable states like antithrombin and protein C deficiency and heparin-induced
thrombocytopenia. It classically presents with sudden onset of lower limb ischemia, which may mimic
post-mortem changes. Infra-renal aortic thrombosis - as in this case - can present with severe lower
extremity pain, paresthesia and neurological deficits and is thought to be secondary to ischemic
peripheral neuropathy. Coagulation disorders have classically been described with AML but they mainly
comprise of hemorrhagic manifestations or small vessel ischemic disease. Large vessel thrombosis is
extremely rare and presence of distal limb ischemia without other constitutional symptoms of fever,
night sweats or weight loss makes this case noteworthy. Exact pathogenesis of aortic thrombosis in AML
is not known. It is hypothesized that immunologic changes in leukemia contribute to the development of
lupus anticoagulant or other procoagulants. These mechanisms can be further fuelled by underlying
leucostasis and DIC, as seen in our patient. Treatment comprises of prompt surgical embolectomy and
short-term anticoagulation.
CONCLUSION: In conclusion, acute aortic thrombosis can result in limb-threatening ischemia and
significant morbidity if not promptly diagnosed. Occult malignancies such as AML should always be a
part of the differential diagnosis in the absence of obvious clinical clues.
A puzzling case of Mycobacterium abscessus
First Author: Amrita Rebecca John, MD,MBBS Senior Author: Steven Opal, MD
Introduction: The incidence of rapidly growing Non-Tuberculosis Mycobacterium (NTM) infection has
been increasing worldwide.
Case Presentation: A 50-year-old female presented with a progressive swelling between the first and
second digits of her right hand of 4 months duration. 3 months after onset, she visited the Emergency
Department, underwent an incision and drainage and took 7 days of Doxycycline. Within a month the
swelling had recurred. Of note, she could recall a small cut on her right thumb while gardening, a week
prior to symptom onset. Exam showed a firm 1.5 x 1 cm swelling between the interdigital space
between her right first and second digits. There was no localized lymphadenopathy or limitation in range
of movements. MRI of the hand reported a hyper vascular enhancing lesion adjacent to the first
metacarpophalangeal joint, without any bony erosions or marrow enhancement. Initial cultures from
the Emergency Department showed gram-positive, auramine/rhodamine fluorescent and acid-fast
positive rods. These organisms were difficult to culture. The sample was processed at 3 different
laboratories before it was identified by nucleic acid analysis as Mycobacterium abscessus, later
confirmed by standard culture and methodology. Surgical excision of the mass revealed necrotizing
granulomatoid nodules with chronic inflammation, granulation tissue and dense fibrosis suggestive of
granuloma annulare on histopathology. Patient was empirically initiated on Clarithromycin and
Doxycycline. Inability to tolerate Doxycycline along with sensitivity patterns showing resistance to this
antibiotic resulted in switching to a combination therapy of Clarithromycin and Ciprofloxacin which has
been successful to date, with no further recurrences.
Discussion: Mycobacterium abscessus (formerly part of “M.chelonae-complex) are the most pathogenic
and chemotherapy-resistant of all rapidly growing Non-Tuberculosis Mycobacterium (NTM). Skin and
soft tissue infections are often secondary to trauma or as a post surgical complication due to
contaminated surgical instruments and supplies. They can occur in both immune competent and
compromised hosts. Molecular tools such as the sequence analyses are preferred in the detection since
methods based solely on microscopy, solid and liquid cultures, Bactec systems, and species-specific
polymerase chain reaction may produce misleading results. M.abscessus is resistant to all first-line
tuberculosis drugs. Early combination therapy is preferred to monotherapy with duration guided by
clinical response. Surgery is indicated for abscesses, extensive disease, when drug therapy is limited by
resistance or adverse effects, and in localized pulmonary disease poorly responsive to medical therapy.
This particular case highlights the need for high degree of clinical suspicion even with absence of a
pathognomonic clinical picture and variable histopathology findings in order to accurately diagnose
rapidly growing Non-Tuberculosis Mycobacterium (NTM) as the cause for recurrent soft tissue swelling.
It is equally important to distinguish M.abscessus since the management and prognosis is different from
other NTM.
The Many Facets of IgG4-Related Disease
1st author: Rajany Dy
2nd author: Stephen Atlas
Introduction: IgG4 related disease is a systemic fibro-inflammatory condition that was recently
recognized when extra-pancreatic manifestations were identified in patients with autoimmune
pancreatitis. Few cases have been reported and randomized trials on the treatment are yet to be
Purpose: To increase clinical suspicion and therefore diagnose IgG4-Related Disease to ensure effective
treatment and prevent complications.
Case Report: A 57 y/o male is seen in the office for an initial primary care visit. He reported that he had
been getting lumps diffusely in the axillary, neck and inguinal areas without pain or drainage since 18
years old and throughout his adult life. 4 years ago, the patient was seen in the ENT clinic for an
enlarging left parotid mass where biopsy revealed sialadenitis with IgG4 plasmacytic proliferation
without clonopathy. 2 years ago, he was seen in the Urology clinic for having symptoms consistent with
benign prostatic hyperplasia. The patient underwent TURP and surgical pathology was reported as
prostatitis with diffuse inflammatory infiltrate consisting primarily of plasma cells, some eosinophils,
lymphocytes and histiocytes. He was admitted 3 times in the past year for acute pancreatitis, which
resolved with conservative management. Abdominal CT showed peripancreatic stranding in the body
and tail with a 1.1 cm peripancreatic lymph node. Chest CT was positive for enlarged axillary,
mediastinal and subcarinal lymph nodes and a pleural-based nodule in the superior segment of the left
lower lobe. The total serum IgG levels were elevated with predominance of subclass 2. Steroids were
started with a prolonged taper of 6 months. Marked improvement was noted after therapy was
initiated. On follow up, the neck and axillary lymphadenopathy were smaller and the patient has not had
any recurrence of pancreatitis. Repeat Chest CT showed an interval decrease in lymphadenopathy with
absence of the previously seen left lower lobe nodule.
Discussion: This patient illustrates the importance of diagnosing IgG4-related disease by means of
clinical suspicion, imaging modalities and histopathology. This condition unifies multiple medical
disorders previously thought as confined to a single organ. It has been described in nearly every organ
system and in this patient, the lymph nodes, pancreas, lungs, salivary glands, and prostate. Although no
clinical trials have been conducted on its management, it is essential that when vital organs are
involved, aggressive treatment should be instituted because the disease can lead to serious organ
dysfunction and failure. Case reports recommend glucocorticoids as the first line of therapy tapered
over a period of 3 to 6 months. For recurrent or refractory disease, B cell depletion with
immunosuppressive agents such as rituximab, azathioprine, mycophenolate and bortezomib have been
suggested useful. Untreated IgG4-related disease often progresses to extensive fibrosis, which is less
likely to have a response to glucocorticoids. Therefore, disease recognition and stabilization is critical for
the patient’s long-term survival.
A Poisonous Remedy: Abdominal Colic and Herbal Supplement Use
Donald F Slack III, MDMichael Lankiewicz, MD
Introduction: Upwards of 40% of Americans take one ormore herbal or dietary supplements every day;
however, physicians often lackformal education on many of these substances. Diagnosing complications
of dietary supplements can therefore present aparticular challenge.
Case Presentation: A 34 year old Indian female witha past medical history of polycystic ovarian
syndrome (PCOS) and nephrolithiasis,with last menstrual period about two weeks prior to admission,
presented withnausea associated with nonbloody emesis, and a 10-day history of gradual onsetof
diffuse, crampy abdominal pain. Reviewof systems was otherwise negative; specifically, she denied any
skin or mucosalabnormalities, easy bruising or bleeding, paresthesias, weakness, or otherneurologic
complaints. Her medicationsconsisted of “ayurvedic therapy" (traditional Indian herbal medicine)which
she began several months prior for treatment of her PCOS. Physical exam was notable for a soft
abdomenwith diffuse tenderness without peritoneal signs or organomegaly, and no oralmucosal, skin or
nail abnormalities. Diagnostic workup was unremarkable other than microcytic anemia(hemoglobin 9.8
g/dL, mean corpuscular volume [MCV] of 79.9 FL), which was initiallyattributed to cyclical menses.
Furtherevaluation, however, revealed normaliron studies and a reticulocyte count of 2.7%. Peripheral
smear showed basophilic stippling and polychromasia, and heavy metals screening yielded elevated
bloodlevels of arsenic (23 ng/mL; reference range 0-12) and lead (86 mcg/dL;reference range 0-9).
Chelation therapywas initiated with dimercaptosuccinic acid and ascorbic acid. At discharge ten days
later, her abdominalpain had completely resolved, and repeat heavy metal screening showed
notablyimproved levels of arsenic and lead. Allsupplements taken by the patient underwent chemical
analysis. A black cohosh liquid tincture had an arseniclevel of 0.0126mg/L, and kachnaar guggul tablets
had a lead concentration of 22mcg/g. To exclude other environmentalsources, her husband and child
were both tested for heavymetal levels with unremarkable results.
Itis imperative that medical
schools and residencies incorporate formal educationon common dietary and herbal supplements into
their primary care rotations sothat future physicians may have informed discussions with their
patientsregarding the benefits and risks their use.
Discussion: The United States Food and Drug Administration must be granted authorityto regulate this
industry with the same oversight applied to pharmaceuticals ifthey are to protect patients and
consumers from misguided consumption of "medicines"at high risk of containing substances such as
heavy metals. As the supplemental industry continues togrow, cases such as this are likely to become
more commonplace.
Stephanie R Wappel, MD
IL-6 Inhibition as Initial Therapy in non-HIV-associated Multicentric
Castleman Disease
First Author: Stephanie R Wappel, MD Co-author: Brett Sperry, MD Georgetown University Hospital,
Department of Medicine
Multicentric Castleman Disease (MCD) is an uncommon lymphoproliferative disorder that typically
presents in HIV-positive patients who are co-infected with HHV-8, the virus associated with Kaposi
sarcoma. The pathophysiology is thought to be related to over-expression of interleukin-6 (IL-6),
causing systemic inflammation. Non-HIV-infected patients with Castleman Disease usually present with
unicentric disease localized to one or several lymph nodes. Non-HIV-associated MCD has been
described but histologic findings are less specific. Patients with MCD typically present with fever and
lymphadenopathy, suggesting infection, and adverse effects from broad-spectrum antibiotic treatment
can render the diagnosis more elusive in HIV-negative patients.
In this case, a previously healthy 47-year-old male presented with abdominal pain and radiologic
findings of cholecystitis. After an uncomplicated cholecystectomy, he developed fever of unknown
origin, anasarca, and mediastinal and intra-abdominal lymphadenopathy. Extensive infectious and
rheumatologic workups were negative. An excisional cervical lymph node biopsy showed prominent
interfollicular plasmocytosis and a hyaline vascular pattern with onion-skinning mantle zones, consistent
with Castleman Disease, but HIV and HHV-8 serologies were negative. Furthermore, medicationinduced thrombocytopenia, persistent fevers, and acute renal failure requiring hemodialysis,
complicated the clinical picture. The patient underwent peritoneal and bone marrow biopsies prior to
arriving at the diagnosis of non-HIV MCD. His serum IL-6 level was markedly elevated at 44.5 pg/mL,
which was consistent with MCD.
Standard therapy for non-HIV MCD is still evolving. Corticosteroids are effective in acute exacerbations
but typically do not induce complete remission. Tocilizumab, a monoclonal antibody against the IL-6
receptor, has been used to induce remission in MCD, although it is currently only approved for this use
in Japan. Rituximab and cytotoxic chemotherapy have been used in advanced cases. This patient's
lymphadenopathy decreased in size after low-dose corticosteroids, but his symptoms otherwise
persisted. Steroids were weaned, and tocilizumab therapy was initiated. The patient’s anasarca
resolved, and his symptoms improved rapidly. The patient underwent his last hemodialysis session ten
days after initiation of tocilizumab. The patient was discharged to continue outpatient infusions. He
subsequently relapsed and required rituximab and cytotoxic chemotherapy in addition to his
tocilizumab infusions.
A diagnosis of non-HIV Multicentric Castleman Disease was made in this patient with abdominal pain,
anasarca, diffuse lymphadenopathy, and fever of unknown origin. Over-expression of IL-6 has been
recognized in the pathogenesis of MCD in both HIV- and non-HIV-infected patients. Tocilizumab, a
monoclonal antibody against the IL-6 receptor, has been used off-label as monotherapy, as well as in
combination with other agents, for MCD. We report a case of non-HIV-associated MCD, complicated by
renal failure and thrombocytopenia, which initially responded well to tocilizumab monotherapy.
TNF inhibitor associated Kikuchi-Fujimoto disease
First Author: Aaron B Heath, DO Julietta Militello, DO Natasha Bray, DO
Kikuchi-Fujimoto disease (KFD) also known as Kikuchi’s histiocyte necrotizing lymphadenitis, originally
described in Japan in 1972 is a rare, benign condition most often found in young Asian women. KFD
typically manifests as cervical lymphadenitis and fever, malaise and fatigue although generalized disease
has been reported. The pathogenesis of KFD is unknown, and though autoimmune and infectious
etiologies have been suggested, the condition is primarily self limiting. The differential diagnosis is
broad and includes lymphoma, viral infections, reactive lymphadenitis, tuberculosis, systemic lupus
erythematosus and metastatic disease. Patients are often misdiagnosed as having lymphoma.
Histopathology of the involved lymph node is necessary to differentiate KFD from several more serious
conditions that it may mimic.
We report a case of KFD associated with use of the TNF inhibitor adalimumab in a 25 year old male with
rheumatoid arthritis.
A 25 year old white male was admitted to the hospital with a 3 month history of intermittent fevers,
night sweats, bilateral cervical lymphadenopathy and 20 pound weight loss. Medical history was
significant for rheumatoid arthritis diagnosed at age 18 treated with adalimumab. Clinical examination
revealed enlarged bilateral tender cervical, axillary and inguinal lymphadenopathy. The patient was
initially treated empirically with antibiotics however no clear source of infection was found. Serology
testing for rheumatoid arthritis revealed high titers for rheumatoid factor and anti-CCP; antibodies, an
extensive autoimmune workup was otherwise negative. Fevers were noted to last approximately 10
days before complete remission and began within 4 days following subcutaneous administration of
adalimumab. PET-CT imaging revealed findings consistent with lymphoma involving Waldeyer’s tonsillar
ring primarily on the left in the oral cavity, a 61mm cluster of left cervical lymph nodes and several large
supraclavicular and left axillary nodes as well as an 18mm left inguinal node. A subsequent excisional
biopsy of a left supraclavicular lymph node was performed. Initial histologic analysis suggested a
peripheral T-cell lymphoma, however further review and consultation demonstrated findings consistent
with KFD.
Autoimmune disorders including rheumatoid arthritis have been suggested in the literature as potential
etiologies for KFD. Here we suggest the TNF inhibitor adalimumab as the culprit. Our patient’s
symptoms, including fever and lymphadenopathy coincided with administration of the medication and
remitted within 2 weeks. Upon discontinuation of adalimumab symptoms completely resolved.
KFD is an uncommon process with an excellent prognosis. However, patients with KFD have been
misdiagnosed with and treated for lymphoma when physicians and pathologists are unfamiliar with this
condition. Accurate pathologic diagnosis is crucial, despite the self-limited nature of the syndrome, in
order to exclude more serious conditions.
Mendoza, MD
First Author: Jerson Munoz Mendoza, MD Second Author: Veronica Pinto Miranda, MD Third Author:
Jodi Renner-Carmona, MD
Introduction: Diffuse cystic lung disease is present in a limited number of pulmonary conditions which
include Langerhans histiocytosis, lymphangioleiomyomatosis, honeycomb lung, advanced sarcoidosis,
and rarely, metastatic disease. Typically, metastatic lesions to the lung present as focal nodules that may
later cavitate. We report a unique case of metastatic sarcoma presenting as diffuse cystic lung disease.
Case description
A 22-year-old man with multiple sclerosis and no history of tobacco use presented with two days of a
non-productive cough and fever. He also endorsed a 20-pound weight loss over six months. His physical
exam revealed a thin man in no distress with normal vital signs and lungs clear to auscultation. On his
upper back, he had an 8 x 5 cm rubbery, erythematous and mildly tender mobile mass that had been
present for weeks but seemed to be increasing in size. Initial laboratory testing was normal except
mildly elevated ESR. His chest x-ray, which was normal 18 months prior, was significant for diffuse
bilateral cysts and a reticulonodular pattern. A noncontrast chest CT showed cysts, cavities, and nodules
too numerous to count involving all lobes of the lung. Additional tests including HIV, alfa-1-antitrypsin,
ANA, ANCA, C3/C4, AFB sputum smear were all normal. Pulmonary function test showed mixed
obstructive/restrictive changes and severely reduced diffusion capacity. The patient had a bronchoscopy
that revealed no endobronchial lesions, and video-assisted thoracoscopic surgery wedge resection of
the right upper and middle lobes. Pathology showed monomorphic, spindle cells, arranged in
storiform/herringbone pattern, positive for CD34 and CD99, negative for keratin, consistent with
metastatic dermatofibrosarcoma protuberans. Upon further questioning, the patient stated he had his
back lesion debrided two years prior, but did not follow-up with his care. His past medical records were
obtained and revealed that the back lesion was dermatofibrosarcoma protuberans. He was referred to
oncology for follow-up of his metastatic sarcoma.
Discussion: This case shows an uncommon cause of diffuse cystic lung disease. The primary tumor,
dermatofibrosarcoma protuberans is a rare cutaneous tumor of low malignant grade that metastasizes
in less than 5% of cases, but has a high propensity to metastasize to the lungs. This diffuse cystic
presentation is uncommon for metastatic neoplasms to the lung, which usually present as localized
nodule. This case highlights the importance of considering metastatic disease as the etiology of diffuse
cystic lung disease when other causes including Langerhans histiocytosis and lymphangiomyomatosis
have been ruled out.
Title and Author Information: Chronic cystitis: Is this in your differential?
Cardona Lyssette MD,Srivastava Alok MD,Seetha Lakshmi MD
All Authors: Seetha Lakshmi, MD Cardona Lyssette MD, Srivastava Alok MD,Seetha Lakshmi MD.
Case Presentation: 40 y/o male presenting with c/o urinary urgency and frequency for 6 months who
had been assessed by several physicians without a diagnosis. He had progressive worsening of urgency
and frequency resulting in nocturia. He did not have any fever, chills, hematuria, dysuria, weight loss or
cough. Over the past 6 months he had received multiple courses of antibiotics for UTI despite the
cultures being persistently negative. His PMH was notable for asthma on inhaled steroids. He lived in
Hong Kong all his life and moved to Florida 3 yrs ago. He had 8.5 pack years of smoking history.
His physical examination was unremarkable with no cost vertebral angle or suprapubic tenderness, no
lymphadenopathy and a normal genital exam. UA showed pyuria and routine urine cultures were
negative. A CT of the abdomen and pelvis demonstrated left hydroureteronephrosis, asymmetric
enlargement of the left kidney with surrounding inflammatory changes as well as prominent
retroperitoneal lymph nodes along with prominent mesenteric calcification. Cystoscopy with biopsy
showed evidence of granulomatous cystitis with non-caseating granulomas.
Based on the above presentation a TB quantiferon, first void urine AFB x3 and CXR were ordered. TB
quantiferon was reported positive so was the urine AFB. His CXR was negative. RIPE Rx was started
pending final culture results.
Urine cultures returned with Mycobacterium TB complex and surprisingly with both MTB and M.bovis
identified by DNA probe analysis.
Discussion: The above case illustrates a young man with chronic cystitis,sterile pyuria and symptomatic
for 6 months before a suspicion of GUTB arose. Given his symptomatology and history of residing in high
prevalence area he had a high pretest probability for TB but his diagnosis was delayed due to lack of
clinical suspicion. The prevalence of GUTB in the United States is 5.7 percent. It is extremely rare to find
a co infection of MTB+ M.bovis causing GUTB (No reported cases on review of current literature)
however in the future may be increasingly appreciated due to availability of PCR testing. Also coinfection with M.bovis has treatment implications since M.bovis are inherently resistant to pyrazinamide
and duration of treatment for M.bovis is 9 months instead of the standard 6 month protocol
recommended for extrapulmonary TB disease.
The Way to a Woman’s Brain is through her Belly?
First Author: Johanna P. Daugherty, MD Second Author: Leonel F. Hernandez, MD Third Author: Himangi
Kaushal, MD, FACP
Introduction: A 19-year-old Haitian female with no significant medical history presented to our ER after
a witnessed tonic-clonic seizure. The seizure was preceded by auditory hallucinations and garbled
speech. One week prior to presentation the patient had experienced periods of confusion and bizarre
behavior per family. Further history was unrevealing.
Case Presentation: On initial exam, the patient was afebrile with a BP of 141/59, HR 130, RR 25, and
oxygen saturation of 97% on 3LNC.
She was lethargic and unable to follow simple commands. She opened her eyes spontaneously and
tracked movements but only maintained short-term eye contact. The remainder of her neurological
exam was normal. Skin exam revealed no rashes, open wounds, or bite marks.
CT and MRI brain were unremarkable. The patient was started on anti-epileptic medication and empiric
antibiotics for bacterial meningitis and HSV encephalitis. Lumbar puncture revealed a lymphocytic
pleocytosis with normal protein. EEG showed epileptogenic potentials in the left temporal region
suggestive of encephalitis. CSF cryptococcal antigen, AFB, HSV PCR, VDRL and fungal smears were
negative. Urine toxicology, heavy metal screen and ammonia levels were also within normal limits.
The patent’s clinical status evolved over the next 10 days with progression to alternating periods of
agitation and lethargy, mutism, development of peri-oral automatisms and tongue and eyelid
fasciculations. She also developed signs of autonomic dysregulation with fever and wide variations in BP
and HR.
Suspicion of a para-neoplastic process prompted an abdominal CT scan which revealed presence of an
ovarian teratoma. Further CSF evaluation revealed the presence of Anti-NMDA receptor antibodies.
IVIG and high dose steroids were initiated and patient underwent surgical removal of the teratoma.
Postoperatively she was treated with cyclosporine. At 6-week follow up post discharge, the patient had
near-total recovery and was planning to resume high school.
Discussion: Anti- N-methyl-D-Aspartate (NMDA) receptor encephalitis is part of the spectrum of
immune-mediated neurologic disorders in which synaptic proteins in the central nervous system are
targets of autoimmunity. It is characterized by a constellation of neuropsychiatric symptoms caused by
specific antibodies targeting the NR1 subunit of the excitatory glutamate NMDA-receptor. This condition
has been associated with the presence of occult tumors in > 50% of cases. Although the most common
tumor found is an ovarian teratoma, other tumors including small-cell lung cancer, Hodgkin´s lymphoma
and germ-cell tumors have been reported. The common denominator is the tumor expression of neuroantigens and the immune cross-reactivity with the NMDA-receptor in the CNS.
This case highlights that early detection and treatment of this condition can limit permanent neurologic
sequelae. There is a need for greater awareness of this disease among internists who are the initial point
of contact for these patients.
The Malignant Truth about Hypercalcemia
First Author: Vikas Khullar MD Second Author: Ankur Jain MD Third Author: Margaret C Lo, MD
Hypercalcemia from squamous cell carcinoma is often mediated by PTH-related peptide (PTHrp). Yet
normal PTHrp values do not exclude this entity given its potential for skeletal metastases.
A 52 year-old, African-American female presented with 2 days of confusion, abdominal pain, anorexia,
and dehydration, after recent discharge for hypercalcemia (14.2 mg/dL) secondary to severe
dehydration. At that 7–day hospitalization, patient had a nondiagnostic hypercalcemia evaluation
including normal PTHrp, intact PTH, SPEP/UPEP, Vitamin D 25-OH levels. Medical history included
steroid-dependent Crohn’s disease and chronic Stage IV sacral decubitus ulcer complicated with
cutaneous squamous cell carcinoma (cSCC) and osteomyelitis s/p sacrectomy and wide local excision
with negative margins. Physical exam exhibited a cachectic, confused female with dry mucosa, skin
tenting, diffuse abdominal tenderness but clean sacral ulcer. Admission laboratory values revealed
severe hypercalcemia (17 mg/dL), mild anemia, thrombocytosis, and hypoalbuminemia. Repeat
hypercalcemia workup demonstrated normal values of PTHrp, intact PTH, and Vitamin D 1,25-OH. Head
CT, 2V-CXR, and KUB were nondiagnostic. Occult malignancy was suspected, despite normal PTHrp
values. A skeletal scintigraphy was negative for bony metastases, showing only specific uptake in the
upper sacrum, consistent with destructive changes from chronic sacral ulcer, as seen on
abdominal/pelvis CT-scans 6 months ago. However, repeat full-body CT-scan revealed T4 vertebral lytic
lesions, necrotic left inguinal lymphadenopathy, and diffuse metastases to the pelvis, liver, and lungs.
Brain MRI showed metastases to the skull marrow space but no masses. Inguinal lymph node
cytopathology confirmed the diagnosis of metastatic, moderately-differentiated cSCC. Patient
responded to IV fluids, calcitonin, and zoledronate. Given poor prognosis from widespread metastases
and failure-to-thrive, she was discharged under hospice care.
This case demonstrates cSCC’s rare ability to induce hypercalcemia via bony metastases, independent of
PTHrp mediation. Literature cites cases of PTH-independent hypercalcemia of cSCC correlating with
susceptibility to develop metastases. The metastatic potential of cSCC arising from chronic skin ulcers is
greater than that of cSCC from normal skin a(30% vs. 3%). These rare malignant Marjolin skin ulcers
develop into aggressive cSCC with high mortality. Additional poor prognostic factors of
hypercalcemia of malignancy include liver metastases, hypoalbuminemia, and calcium>11.83mg/dL, all
present in our patient. Skeletal scintigraphy is the preferred imaging modality for detection of bony
metastases in cancer-induced hypercalcemia; however, its diagnostic value remains poor for lytic
metastases (sensitivity of 62%-100% and specificity of 78%-100%). Experts recommend targeted CTscans or PET/CT-scans to increase detection of both lytic and blastic skeletal metastases in highlysuspected cases. Clinicians must understand the diagnostic dilemma created by normal PTHrp and
skeletal scintigraphy and recognize the need for CT imaging to detect skeletal metastases before
excluding hypercalcemia from cSCC, especially in high-risk patients with Marjolin ulcers, malnutrition,
and severe hypercalcemia.
A rare association between active Ulcerative Colitis and immune
First Author: Sandra Rodriguez, MD John Rivas, MD, Brent Murchie, MD, Leyla Maric, MD, Roger Charles,
Ulcerative Colitis (UC) is associated with multiple extra intestinal manifestations. However, its
association with immune-mediated throbocytopenias is uncommon. Idiopathic Thrombocytopenia
Purpura (ITP) is a form of thrombocytopenia in which platelet destruction is caused by a disturbance of
the immune system leading to the formation of platelet specific antibodies. Rapid platelet clearance and
destruction is mainly the result of phagocytosis by splenic leukocytes. The pathologic mechanisms
proposed for the rare association between IBD and ITP likely involves enhanced exposure of the
intestinal immune system to luminal antigens and antigenic mimicry between platelet surface antigen
and bacterial glycoprotein. During an acute exacerbation of UC there is an increase in the mucosal
permeability and therefore increase antigenic exposure.
Here we present a case of a 32 year-old male with a history of UC for over 12 years involving the rectum
and sigmoid colon in remission, who presented at twelve weeks of recurrent symptoms after
discontinuation of maintenance therapy with 6-mercaptopurine (MP) by his primary care physician.
Colonoscopy showed active sigmoid colitis with crypt abscesses for which 6-MP was reinitiated. Patient
responded appropriately to treatment with clinical improvement in symptoms and was discharge home.
A few days later, he was subsequently readmitted with worsening abdominal pain, diarrhea, and bright
red blood per rectum. Extensive diagnostic work up was only significant for a very low platelet count and
a high lactate dehydrogenase level. Hematology was consulted, for acute onset of thrombocytopenia. A
peripheral smear showed a left shift, reactive lymphocytes, and few large megakaryocytes consistent
with ITP. IV steroids were started, which resulted in symptomatic improvement and recovery of
the platelet count. Patient was subsequently discharged home on prednisone with hematology followup.
The association between UC and ITP is rare. However, an ITP-like syndrome should be suspected in
patient with active colitis, low platelet count, and large platelets on peripheral smear. Most cases
respond very well to steroids. The proposed mechanism entails an increased luminal antigenic exposure
as a result of bowel inflammation which results in altered immunoregulation.
The Lonely Platelet: A Case of Refractory Thrombocytopenia in a patient with
long history of ITP
Thomas Starnes MS, Meghan Harris MD, Smitha Pabbathi MD Moffitt Cancer Center Department of
Internal Hospital Medicine University of South Florida Morsani Col
Introduction: Refractory ITP is defined as persistent, prolonged thrombocytopenia with platelet count
below 50,000 without a response to splenectomy and rituximab. We present a case of a patient with a
30 year history of ITP, status post splenectomy, intravenous immunoglobulin (IVIg), rituximab, and on
high dose prednisone admitted for recurrent thrombocytopenia.
Case Presentation: A sixty-year-old woman presented with one week of progressive shortness of breath
and fatigue. She also reported sharp, left-sided chest pain with inspiration, nonproductive cough and
hematuria. On exam, she was lethargic. Temperature was 36.3 degrees Celsius, pulse 100/min and
regular, blood pressure 179/90 mmHg, respiratory rate 22/min, and oxygen saturation 95% on room air.
She demonstrated characteristic moon facies and buffalo hump. No JVD was noted. Breath sounds were
diminished with fine crackles in the left upper lobe. Multiple petechiae were noted on all four
extremities. External genitourinary exam revealed multiple perineal subcentimeter bleeding ulcerations.
Initial laboratory studies were significant for a platelet count of 5,000/microliter, hemoglobin of 13 g/dl,
and white blood cell count of 11,750/microliter with left shift. Imaging of the brain was negative for
intracranial hemorrhage or posterior reversible encephalopathy. Chest CT revealed nodular opacities
and a focal subpleural consolidation in the left upper lobe. The patient was placed empirically on
meropenem, trimethoprim/sulfamethoxazole, and voriconazole. Urine Streptococcus and Legionella
antigens were negative. HIV and hepatitis serologies were negative. There was no evidence of acid-fast
bacilli, Nocardia or PCP on bronchoalveolar lavage, but CMV PCR revealed 2,870,000 copies/ml. CMV
PCR of serum also revealed 198,000 copies/dL. After initiating gancyclovir and IVIG, her platelet count
steadily recovered to 152,000/microliter. There was complete resolution of frank bleeding from the
perineum and improvement of the petechial lesions. With continued treatment, her mental status and
energy level improved.
Discussion: Refractory ITP has been linked to untreated viral syndromes such as HIV, hepatitis, and CMV
infection. Patients who are on chronic immunosuppression with high dose steroids can have
reactivation of CMV resulting in relapse of their ITP. This phenomenon has been described in the
literature. Although rare, patients with a long history of ITP who exhibit severe thrombocytopenia can
do so secondary to a de novo process. This case illustrates the importance of testing for underlying viral
syndromes, such as CMV, as part of the work-up for refractory thrombocytopenia. In our patient,
combination therapy was administered with IVIG and gancyclovir while continuing her high dose
steroids. She had dramatic improvement in her platelet count upon discharge. Four weeks following
discharge, our patient’s CMV PCR was reported to be less than 250 copies/ml and her platelet count was
maintained above 50,000/microliter.
A Thorn In The Duodenum: A Rare Complication of IVC Filter Placement
First Author: Jasmin Martinez, MD Nicholas Hartmann MD, Alberto Zarak MD, Sarah Bland MD
Introduction: The inferior vena cava (IVC) filter remains an invaluable tool in the prevention of
pulmonary embolism (PE) in patients who have failed or have a contraindication to anticoagulation. The
incidence of symptomatic caval perforation due to an IVC filter is approximately 0.3%. In this report, we
discuss a rare case of recurrent abdominal pain secondary to IVC filter strut caval perforation involving
the duodenum.
Case Presentation: A 69 year-old woman with a history of DVT and recurrent PEs status post IVC filter
placement 2 years prior to presentation was admitted to our service complaining of right lower
quadrant abdominal pain, nausea, fatigue, headache, chills, fever and constipation for 2 days. She
reported a history of several similar episodes in the past 6 months. The IVC filter was placed with the
thought of avoiding long-term anticoagulation.
On physical exam, she was afebrile with normal vital signs. Her exam revealed a soft, slightly distended
abdomen that was tympanic to percussion, tender to deep palpation in the right lower quadrant, and
normal bowel sounds. Her right lower extremity had venous stasis hyperpigmentation with a diameter
that was greater than the left. Her labs were remarkable for mild leukocytosis, macrocytic anemia,
elevated AST and alkaline phosphatase. Venous duplex ultrasound revealed an occlusive thrombus in
the right posterior tibial vein. A CT of her abdomen/pelvis was remarkable for IVC filter struts appearing
to extend beyond the margins of the vessel, with one of the struts extending beyond the confines of the
IVC to the second portion of the duodenum. Upper endoscopy revealed a linear metallic foreign body
with a hooked end penetrating the medial wall of the second portion of the duodenum.
An exploratory laparotomy showed significant fibrosis and inflammation between the duodenum and
the inferior vena cava, and four struts extruding from the IVC wall, with one of them penetrating into
the second portion of the duodenum. All the struts were trimmed ?ush with the IVC. An intraoperative
EGD was done to confirm the release of the strut in the duodenum, and to snare and remove it. She had
an uncomplicated post-operative course with complete resolution of her presenting symptoms. She was
discharged home after receiving a heparin bridge to a therapeutic INR for lifelong warfarin therapy.
Discussion: In patients with a history of IVC filter placement presenting with abdominal pain, one must
consider caval perforation. When imaging studies suggest perforation into the gastrointestinal system,
endoscopic evaluation is warranted. If confirmed, resolution of the symptoms may be achieved with the
removal of the struts without removal of the IVC filter.
Diabetic Ketoacidosis in a Non-Diabetic Patient
First Author: Jennifer L Horsley-Silva, MD Second Author: Gregory L Repass MD Senior Author: Jeffrey L
Garland MD
A 57 year-old Chinese female with no prior history of diabetes was admitted in critical condition after
being found unresponsive. Patient had a history of a metastatic neuroendocrine carcinoma and had
been undergoing treatment with Streptozotocin, Sandostatin, Fluorouracil, and Zoledronic Acid. Last
chemotherapy was sometime in the last 4-6 weeks. Upon arrival to the emergency department she was
unresponsive and hypotensive. During intubation she was discovered to have blood coming from her
gastrointestinal tract. Initial arterial blood gas revealed a serum bicarbonate of 5mmol/L and a
hemoglobin of 5g/dL with unreadable pH. Patient was found to have an acute esophageal variceal
hemorrhage, respiratory failure, critical anion gap and non-anion gap metabolic acidosis, lactic acidosis,
diabetic ketoacidosis, hypovolemic shock, critical electrolyte disturbances, and a comatose state. The
anion gap metabolic acidosis included positive lactic acid, beta-hydroxybutyrate and acetone with initial
blood glucose of 861mg/dL. After intubation she was aggressively resuscitated and
esophagogastroduodenoscopy was performed with sclerotherapy applied to esophageal varices as
banding was unsuccessful. Her metabolic acidosis was refractory for first several days of hospitalization
with intervention including continuous insulin infusion, bicarbonate ampules and continuous infusion,
and fluid resuscitation. She required therapy with multiple vasopressors and once stable, computed
tomography imaging was performed which disclosed a small superior frontal subarachnoid hemorrhage
and a porta-splenic and superior mesenteric vein thrombosis. Subarachnoid hemorrhage was stable and
improved on serial imaging. Her venous thrombosis was presumed secondary to hypercoaguable state in
the setting of metastatic neuroendocrine carcinoma. While initially comatose, patient had a marked
neurologic recovery following initial resuscitation and was able to be extubated and was improving
clinically until she became acutely comatose. An extensive work-up disclosed evidence of diffuse
cerebral edema with cause presumed toxic/metabolic encephalopathy. She did not respond to
attempted treatment and remained unresponsive until her death.
Streptozotocin is an alkylating agent used for treating cancer of the Islets of Langerhans by causing
toxicity to the beta islet cells that produce insulin in the pancreas. It has been approved by the FDA since
1982 for use in metastatic cancer of pancreatic islet cells. It is a toxic medication used in severe cases of
metastatic cancer and has been used to induce diabetes in mammals. Studies have also shown that
diabetes increased the conversion of glucose to lactate by fat cells, leading to elevated lactate. We
believe our patient developed severe metabolic acidosis and diabetic ketoacidosis as a side effect from
this medication. Given the known toxicity of this medication, patients should be educated for prompt
recognition of symptoms of acidosis so that supportive measures can be taken as quickly as possible.
LaRocca, MD
A Rare Case of Sclerosing Mesenteritis
First Author: Tulisa Hanflink LaRocca, MD
Introduction: Sclerosing mesenteritis is part of a continuum of idiopathic primary inflammatory and
fibrotic processes that affect the mesentery. Also known as mesenteric lipodystrophy or mesenteric
panniculitis, it was first given clinical and pathologic identity within the last 50 years. A report in 1960 by
Ogden, Bradburn, and Rives described seven patients with recurring episodes of moderate to severe
abdominal pain, intermittent nausea, fever, malaise, and in over half of the cases, a palpable abdominal
mass. Pathologic evaluation revealed “extensive involvement of the mesentery of the small bowel by a
chronic inflammation.” Of clinical importance is the association of sclerosing mesenteritis with
autoimmune disease, carcinoma, and lymphoma.
Case Presentation: We present a 62 year old female with a 3 day history of diffuse dull abdominal pain
associated with nausea and diarrhea. She reports bouts of nausea intermittently for a year, for which
she has taken Dramamine as needed. She reports seeing a gastroenterologist 2 months ago, who
diagnosed gastritis. On physical exam, she had tenderness in the epigastric region with radiation to the
left upper quadrant and mild abdominal distention. No discrete masses were palpated. Laboratory
studies were unremarkable. CT abdomen showed mass-like streaky densities in the mesenteric fat and
several small mesenteric lymph nodes, consistent with sclerosing mesenteritis. An exploratory
laparoscopy with mesenteric biopsy revealed a fibroadipose mass in the mesentery with exuberant
xanthomatous inflammation negative for carcinoma and lymphoma.
Discussion: Fewer than 100 cases of sclerosing mesenteritis have been reported in the literature, with
even fewer cases diagnosed pre-autopsy. It is now believed to be a continuum, beginning with
mesenteric lipodystrophy, progressing to mesenteric panniculitis, and resulting in sclerosing
mesenteritis. The epidemiology is unknown; an autopsy series reported a prevalence of one percent—
suggesting many cases remain undiagnosed during life. Most patients are male, white, and in their fifth
to seventh decades of life. The cause remains unknown, the pathogenesis ambiguous, and the natural
history indefinite. Clinical presentation may vary from an asymptomatic incidental finding on imaging to
a systemic syndrome involving fever, malaise, and intestinal obstruction. Laboratory studies are usually
normal, with occasional elevated markers of inflammation. The most sensitive modality for diagnosis is
CT; a finding termed “misty mesentery” can also be noted, as described above. Imaging is usually
followed by surgical biopsy for diagnosis and exclusion of malignancy. Diagnosis is rarely made
preoperatively. Treatment includes immunosuppressives, with surgery reserved for obstructive
complications. The clinical course is usually benign with successful medical and surgical management.
This rare, often misdiagnosed entity can cause significant discomfort and distress to patients. It is thus
important to raise awareness of this process and facilitate accurate diagnosis.
B-Cell lymphoma presenting as a pathological fracture
First Author: Julietta Militello, DO Aaron B. Heath, DO, Shaakir Hasan, Kyle Leneweaver, Natasha Bray,
DO, Archana Maini, MD
Non-Hodgkin’s Lymphoma (NHL) originating in bone is referred to as a Primary Bone Lymphoma (PBL).
This occurs in only 2% of all NHL; of these even less manifest as a pathologic fracture. PBL lacks a specific
presentation and thus can make diagnosis difficult and delay treatment. Once diagnosed, treatment is
consistent with other NHLs, with the additional challenge of preventing or stabilizing a pathological
fracture. We present a case of a femoral fracture that led to a diagnosis of NHL.
A 61-year-old female presented with excruciating pain to the left thigh and a deformed left lower
extremity. While walking she heard a snap and fell to the ground with severe pain. On physical
examination, the left thigh was swollen and laterally angulated, with the skin intact. Upon further
questioning the patient complained of a dull aching pain in the same area for 2 months that began after
falling from a horse. The patient did not have any imaging of the affected leg and received only
supportive care with NSAIDS.
A CT scan of the left leg revealed a diaphyseal fracture, with a thickened cortex of 11 mm and a small
lytic lesion near the fracture site. The fracture was reduced in buck’s traction. She underwent fixation by
intramedullary rodding. Intra-operatively, a fibrous soft material near the fracture site was biopsied.
Pathology revealed Diffuse Large B-cell Lymphoma, and tested positive for CD45, CD20, and CD79a.
Further metastatic workup including CT of the chest, abdomen and pelvis as well as PET scan was
negative. The patient was treated with 40 Gy of radiotherapy directed at the mid femoral shaft. The
patient is scheduled to receive chemotherapy with R-CHOP (Rituximab, Cyclophosphamide,
Hydroxydaunomycin, Oncovin, Prednisone) upon completion of her physical rehabilitation.
This case is unique in that the presentation at diagnosis was a fracture. Usually PBLs present as
persistant swelling and dull pain, which prompts radiological studies and subsequent diagnosis. The CT
scan on admission revealed osteolytic lesions near the fracture site suggesting that the diagnosis could
have been made earlier and the fracture may have been prevented. Management of patients includes
R-CHOP and radiation therapy which leads to higher survival rates when employed together. Radiation
therapy may be complicated due to the internal fixation that can cause scattering of the radiation beam
which is compensated for by using multiple fields.
An unusual cause of abdominal pain in a young patient with SLE: The hidden
First Author: Carolina Mejia, MD second author: Luis Arias, MD
A 28-year old female, was diagnosed with Systemic lupus erythematosus (SLE) in 2006 after the onset of
arthralgia, fatigue, leucopenia and positive ANA. She had received high-dose steroids at the time of
diagnosis and later on switched to hydroxychloroquine 300 mg/day. More recently she was started on
prednisone and was taking 2 mg per day due to persistent disease activity (mainly arthralgia). She
presented with severe abdominal pain described as colic in nature, nausea, vomit and non-bloody
diarrhea of 4-5 days duration. Her abdomen was distended and tender to palpation throughout.
Laboratory results were remarkable for anemia and leukopenia; serum amylase and lipase were normal
and stool cultures were sterile. A CT of the abdomen demonstrated marked bowel wall thickening and
submucosal edema throughout the ileum and cecum engorged mesenteric vessels compatible with ileal
enteritis. The patient was started on levofloxacin and metronidazole, as well as her usual SLE
medications, with only a slight clinical improvement. However, she persisted with abdominal pain
leading to a CT angiogram of the abdomen which revealed new marked bowel wall thickening and
submucosal edema involving the dilated third portion of the duodenum and jejunal loops. Further
diagnostic studies revealed normal C-Reactive protein and erythrocyte sedimentation rate, normal
urinalysis, low C3 and C4 and positive Anti-ds DNA antibody (300 UI/ML titer by EIA). Patient was started
on IV methyl prednisolone 1mg/kg/day for the treatment of lupus mesenteric vasculitis, and then
switched to PO prednisone with adequate clinical response.
Lupus mesenteric vasculitis (LMV) is one of the main causes of acute abdominal pain in SLE patients but
LMV is generally an uncommon condition; the global prevalence ranges from 0.2% to 9.7% among all SLE
patients. It usually occurs in patients with active lupus, and has been shown to have strong association
with the presence of peripheral vasculitis, central nervous system disease, ischemic bone necrosis and
thrombocytopenia, none of these present in our patient. Patients on long-term steroids are prone to
development of atherosclerotic vascular disease, which may predispose to mesenteric vascular
ischemia. Antiphospholipid antibodies may also predispose to induction of intestinal infarction. Our
patient, however, lacked anticardiolipin antibodies. Other proposed trigger factors include bacterial
infections that lead to changes of intestinal flora, cytomegalovirus infection, eosinophilia, chemicals,
certain foods and herbal medicines.
Typically, LMV causes diffuse abdominal pain, sometimes with rebound tenderness and abdominal
muscle guarding. Other manifestations of LMV include anorexia, nausea, vomiting, dysphagia,
hematemesis, postprandial fullness, diarrhea and melena. The diagnosis of LMV relies on abdominal
computed tomography (CT) scan; Common CT findings in patients with LMV include dilated bowel, focal
or diffuse bowel wall thickening, abnormal bowel wall enhancement (“target sign”), mesenteric edema,
stenosis or engorgement of mesenteric vessels (“the comb sign”) and ascites. Treatment of choice is 1-2
mg/kg of parenteral methyl prednisolone or its equivalent in addition to bowel rest. For patients with
recurrent LMV and those who do not have adequate response to intravenous prednisolone alone,
intravenous cyclophosphamide should be initiated.
Hemorrhagic Form of Crohn’s Disease
First Author: Leyla V Maric, MD Leyla Maric MD, Sandra Rodriguez MD, John Rivas MD, Brent Murchie
MD, Roger Charles, MD
Crohn’s Disease (CD) is an Inflammatory Bowel Disease, most commonly diagnosed in second or third
decade of life, but may occur at any age. There is no gender predominance, and approximately 1.5
million Americans have this disease. CD is characterized by indolent onset and variable clinical
manifestations that depend on the location of disease and the presence of complications such as
strictures or fistulas. With ileocecal disease, abdominal pain, diarrhea and fever are typical. With colonic
disease, bloody bowel movements with diarrhea, weight loss and low-grade fever are common.
Microscopic bleeding is common in CD, but gross blood in stool is very uncommon.
We present a case of a 39 year old male with PMH of Ileocolonic CD requiring terminal ileal/cecal
resection, who was doing well on Infliximab. He presented to the ED with three episodes of massive,
painless hematochezia within 24 hour period. On presentation, pt was tachycardic with positive
orthostatic vital signs. BRBPR mixed with maroon colored liquid stool was noted on rectal exam.
Laboratory studies revealed an acute drop in Hemoglobin/Hematocrit and elevated BUN within less than
12 hours of admission. EGD and tagged RBC scan were negative. Bedside colonoscopy revealed an
actively bleeding ulcer on colonic side of ileocolic anastomosis, which continued to bleed despite the
injection with Epi and cauterization. Pt required transfusion with pRBC’s and FFP, but bleeding
continued. He was taken to the OR, and underwent Repeat-Ileocolic resection. Pathology report was
consistent with anastomotic line that was patent and intact, and focal ulceration that was present at
ileal margin. Findings were consistent with Hemorrhagic form of CD.
CD is an unusual cause of massive GI bleed and it occurs in 0.9-6% of pts. There are no identifiable risk
factors. Massive GI bleed may reveal up to 23% of new cases of Crohn’s. There is usually a localized
source of the bleed such as an ulcer. Site of bleed most likely follows the distribution of disease.
Proposed pathogenesis of hemorrhagic Crohn’s disease is transmural inflammation leading to erosion of
large vessels and/or Acquired Factor XIII deficiency secondary to plasma protein depletion via GI
leakage. Hemorrhagic CD is best diagnosed with combination of angiography and endoscopy. Endoscopy
has a good diagnostic yield but poor therapeutic role in management of these pts, and surgery should be
recommended in pts with massive bleeds who are hemodynamically unstable despite blood product
transfusion, and pts with recurrent massive hemorrhage. Several studies claim that Infliximab can be
used to treat hemorrhagic type of CD however, our pt was on Infliximab at the time of the acute episode
of massive GI bleed which makes our case presentation unique.
Freeman-Keller, DO
Cannabis Hyperemesis Syndrome: An Emerging Cause of Intractable Nausea
and Vomiting
Morganna Freeman-Keller, DO
In 2009, there were 4.6 million drug-related ED visits nationwide - almost one million involving an illicit
substance, with nearly 400,000 related to marijuana use. A recent WHO survey found the US is the
world’s leading per capita marijuana consumer, with approximately 15 million users (an estimated
15.7% of which use marijuana on a daily or almost daily basis). This has led to the emergence of adverse
health effects, most recently reports of a cyclical vomiting syndrome related to heavy cannabis use.
Here we describe a longstanding marijuana abuser with a nearly decade-long history of recurrent
hospitalizations for nausea, vomiting, and abdominal pain.
A 36 year old male with a history of uncontrolled HTN, polysubstance abuse and medical noncompliance
presented to our hospital with intractable abdominal pain, nausea and vomiting. He had similar
presentations in April and September 2011, with UDS positive for cocaine, cannabinoids, and opioids.
Each time he was diagnosed with “gastroenteritis” and poorly controlled HTN due to not being able to
keep down oral BP meds; he recovered with IV fluids and was discharged home within 24 hours.
On this admission he reported severe vomiting with colicky abdominal pain but denied fever, chills,
unusual food, or sick contacts. Social history was positive for cocaine and opiate use as well as smoking
marijuana “up to four grams a day.” He was noted to be hypertensive and again reported missing BP
medications because of vomiting. Physical exam showed mild abdominal tenderness but was otherwise
unremarkable. CT of the abdomen showed no acute findings. Admission lab workup showed no
leukocytosis, electrolyte derangement, elevation in transaminases, or lactic acidosis.
On review of prior records, he had multiple admissions since 2004 for the same complaints and each
time was given a diagnosis of “gastroenteritis.” Numerous GI workups were negative (including multiple
CT scans of the abdomen); UDS was repeatedly positive for cannabinoids. Suspecting hyperemesis
relating to marijuana abuse, he was treated with IV hydration and antispasmodic agents. He recovered
uneventfully and was counseled on the need to quit smoking marijuana if he hoped to improve his
Cannabinoid hyperemesis was first described by Allen in 2004, and is defined as excessive marijuana use
associated with cyclical vomiting and abdominal pain. Delta-9-tetrahydrocannabinol, also known as THC,
acts on CB1 receptors in the brain and gut; toxic accumulation of THC may lead to delayed gastric
emptying or even gastric stasis. Recent literature suggests it is poorly recognized and reported in clinic
and emergency department settings, thus this often-missed diagnosis results in repeated
hospitalizations and unnecessary diagnostic testing. Advancements in plant cultivation have resulted in
higher THC-containing domestic marijuana, and this coupled with increasing population use lends
importance to early recognition by treating physicians.
Choksy, MBBS
Significance of ST elevation in Often Overlooked Lead aVR
Pratik Choksy, MBBS Shumile Zaidi, MD Pascha Schafer, MD
Introduction: The benefit of emergent reperfusion therapy with fibrinolytics or percutaneous coronary
intervention (PCI) is well known for patients with acute ST elevation myocardial infarction (STEMI) on 12
lead electrocardiogram (EKG). Acute coronary syndrome (ACS) without STEMI does not have clear
guidelines for emergent reperfusion therapy. Often overlooked subgroup of ACS is patients with isolated
ST elevation in lead aVR. Few studies have shown strong correlation of isolated ST elevation in lead aVR
to occlusion of left main (LM) or proximal left anterior descending (LAD) coronary artery putting such
patients at very high risk for mortality. This high risk subgroup of ACS should undergo emergent
reperfusion therapy. We hereby present 2 such cases with ST elevation in lead aVR.
Case 1: 40 year old male with history of tobacco and cocaine use presented with sudden onset of severe
chest pressure with radiation to left arm which relieved with 1 nitroglycerin tablet in emergency room
(ER). He had stable vitals on presentation with initial troponin of 0.03 ng/ml and EKG showing ST
depression in anterolateral leads and ST elevation in lead aVR. Subsequently 2nd troponin was 15 ng/ml
and he underwent emergent left heart catheterization (LHC). It showed 95% blockage of proximal LAD
which was intervened and bare metal stent was placed. He remained chest pain free and was discharged
home next day.
Case 2: 71 year old female with no past history presented to outside emergency room with severe chest
pressure, nausea and diaphoresis. Her initial EKG showed 1-2 mm ST elevation in lead V1, V2 and aVR
and troponin of 12 ng/ml. She was given tenecteplase and was then transferred to our hospital. On
arrival she was chest pain free and her EKG showed ST depressions in inferolateral leads, ST elevation in
lead aVR and minimal ST elevation in V1. Few hours later, she had another episode of severe chest
tightness and became hypotensive and tachycardic. She was taken emergently for intra-aortic balloon
placement and LHC and was found to have greater than 95% blockage in distal LM and ostial LAD with
thrombus and 70-80% blockage in left circumflex artery. Patient was emergently taken by
cardiothoracic surgery for coronary artery bypass grafting (CABG). Unfortunately, she died during
hospital stay post-surgery.
Conclusion: ST changes in lead aVR are often overlooked on EKG. Physician’s especially ER doctors
should be aware about the strong correlation of isolated ST elevation in lead aVR with LM or LAD
occlusion. It will help in early identification of this high risk subgroup of ACS leading to administration of
reperfusion therapies in timely manner.
Hyponatremia: the cause or the effect of altered mental status?
First Author: Meghan M Lyman, MD
Introduction: Hyponatremia and altered mental status are two diagnoses that commonly accompany
one another but their interaction varies from case to case. Often, acute hyponatremia causes confusion,
seizures, and coma but the reverse is possible, where a catastrophic neurological event can cause
hyponatremia. Also possible, a third factor such as infection, thyroid disease, or adrenal insufficiency
can lead to both hyponatremia and altered mental status.
Case Presentation: A 94yo man with history of hypertension and prostate cancer presented to the
emergency room with nausea/vomiting and disoriented per primary caretaker. Six weeks before, he
presented with similar symptoms that were attributed to gastritis and a urinary tract infection. He was
also having more difficulty with swallowing and had decreased oral intake over the past few weeks.
In the ER, he was found to be hypertensive but orthostatic. He was confused, alert and oriented to
person only which differed from baseline. There were no abnormalities on exam and no focal
neurologic deficits were documented. Initial labs were significant for hyponatremia (Na=119) and
hypochloremia. His random cortisol and TSH were normal. His measured serum osmolarity was low
(254) and urine sodium elevated (109). These abnormalities were presumed to be hypovolemic in
etiology, given his orthostasis and history of decreased oral intake so he was given normal saline but had
no subsequent improvement in sodium level. This made the team concerned that the patient was not
simply dehydrated but may have SIADH. Six hours later, the patient was not responsive to sternal rub.
Given his rapid deterioration in mental status, he had a head CT which showed a very large
intraparenchymal hemorrhage with herniation and midline shift. After the CT results were obtained, it
was felt that his hyponatremia was likely due to cerebral salt wasting in the context of an intracranial
Discussion: Cerebral salt wasting should be considered as the etiology of hyponatermia in the setting of
hypovolemic hyponatremia with a low measured serum osmolality and high urine sodium
concentration. This condition often resembles SIADH except that patients are euvolemic in SIADH and
hypovolemic in cerebral salt wasting. This case illustrates that hyponatremia can occur as a result of a
primary neurological process, instead of being the primary cause of the neurological symptoms. It is
prudent to evaluate for neurological abnormalities in patients who present with hypovolemic
hyponatremia and altered mental status as hyponatermia may not be the single etiology of their
symptoms. In this case, the patient’s hyponatremia preceded his rapid neurological deterioration.
Neurological processes such as stroke, hemorrhage, tumor, and infection should always be kept on a
clinician’s differential, so that they can be detected early enough for successful intervention.
Gardner, MD
Dofetilide-Induced Torsades de Pointes in a Patient with Takotsubo
Jonathan D. Gardner, M.D., Joe B. Calkins, M.D., David Haburchak, M.D.
Introduction: Acute symptomatic atrial fibrillation is a common malady associated with aging, usually
responsive to dofetilide when given by protocol to avoid induction of torsade. In our case, torsade
occurred and was retrospectively found to be associated with takotsubo cardiomyopathy. The direction
of causation in this case cannot be determined, but the association should be considered when using
Case: The patient is a 66 y/o WF who was admitted for symptomatic atrial fibrillation with rapid
ventricular rate. She received a TEE guided cardioversion resulted in brief restoration of sinus rhythm,
but atrial fibrillation recurred. EF was moderately reduced at 30-35%. Dofetilide 500 mcg was started
with a baseline QTc of 498 msec. Two hours after initiation, the QTc was 507 msec. The following day,
the patient received 500 mcg of dofetilide. Her QTc increased to 573 msec and cardiac arrest occurred.
Chest compressions were initiated. Review of the monitor showed ventricular fibrillation, compressions
were resumed followed by 200 J shock. Her pulse was palpated, she regained consciousness, and the
monitor showed ventricular tachycardia. EKG showed an irregular wide complex tachycardia. The
patient was given an amiodarone bolus and magnesium sulfate. Review of the initial telemetry showed
torsades de pointes. She was admitted to the CCU and dofetilide was discontinued. The patient had a
TTE, which showed globally reduced EF of 10-15% and apical ballooning of the left ventricle consistent
with takotsubo cardiomyopathy. LHC revealed non-obstructive CAD. Cardioversion was performed and
she converted to normal sinus. Follow up TTE showed improved cardiac function and resolution of apical
ballooning. The patient was discharged home in stable condition.
Discussion: Dofetilide is a class III antiarrhythmic used to treat AF in patients with reduced EF. It blocks
the delayed rectifier cardiac potassium channel and prolongs repolarization. When dofetilide therapy is
initiated, a specific protocol is followed. A QTc greater than 440 msec or a CrCl less than 20 ml/min is a
contraindication to dofetilide therapy. Takotsubo cardiomyopathy is a syndrome commonly associated
with post-menopausal women. It is characterized by a transient systolic dysfunction of the apical
segments of the left ventricle. The pathogenesis is not well understood, but it is triggered by an acute
medical illness or emotional or physical stress. Takostubo cardiomyopathy classically simulates an MI
with the presence of ST elevations and can result in heart failure, arrhythmias, MR, or cardiogenic
shock. It can be associated with prolonged QT and T-wave inversions. Specific echo findings are apical
ballooning with akinesis or dyskinesis.
Conclusion: The QT prolongation leading to VT/VF is a well-described adverse affect of dofetilide. The
hyperadenergic state associated with the arrhythmia and resuscitation may have led to the
development of takotsubo cardiomyopathy, but is not conclusive. Thus, a close temporal association
between these events suggests a possible cause and effect relationship.
CPT Sarah Gordon, MD (Associate)/ MAJ Alice Uy, MD/ LTC(P) Troy Denunzio, MD (Member)
Introduction: Standard treatment for class III, IV, and/or V lupus nephritis (LN) is a combination of oral
corticosteroids and mycophenolate mofetil (MMF). Recent studies have evaluated the use of tacrolimus
as adjunctive therapy, particularly in treatment failures.
Case Series: Six female patients with biopsy proven proliferative or membranous LN with prior
treatment with MMF and prednisone were started on tacrolimus with a serum trough goal of 4-6 ng/mL.
There were two patients with class IV LN, two with class IV/V LN, one with class III/V LN, and one with
class V LN. Five of the patients were Caucasian, and one was Asian. All were on an angiotensin
converting enzyme inhibitor or angiotensin receptor blocker. Two patients had previously received
rituximab during flares. Mean tacrolimus level ranged from 3.0-6.56 ng/mL. There were no adverse
effects reported. Three patients experienced complete remission (proteinuria <0.33g/day), two patients
had a partial remission, defined as 50% reduction in baseline proteinuria (87% and 93%). Albumin
increased an average of 32%. Average C3/C4 levels were 64/15, respectively, prior to treatment and
95/25 following treatment. The median treatment duration prior to maximum decrease in proteinuria
and improvement in serum complement levels was 5 months. None of the patients had an increase in
serum creatinine to greater than 20% from baseline.
Discussion: Approximately 60% of systemic lupus erythematosus (SLE) patients will experience renal
complications. Treatment of LN is based on histopathologic diagnosis and staging by International
Society of Nephrology/ Renal Pathology Society (ISN/RPS) classification. An accepted therapy for III, IV,
and/or V consists of corticosteroids and MMF with an estimated failure rate of 16%. Cyclophosphamide
is an alternative therapy, but has a more toxic side effect profile. Several small studies have looked at
the use of tacrolimus in class III, IV, and V LN, both as induction treatment and as maintenance in
patients refractory to other treatments. The majority of these studies were conducted in Asian patients,
and one study investigated use of tacrolimus in African American and Caucasian patients. Our case
series supports the growing body of evidence that tacrolimus is an effective adjunctive therapy in LN
patients with refractory proteinuria. We have not observed evidence of tacrolimus nephropathy or
other adverse effects to date. Our current data lacks long term follow up. Large studies are required to
establish appropriate trough goals and duration of therapy, and long term safety and efficacy of
Sulfasalazine Induced DRESS syndrome: A clinical case
First Author: Marco A Paez, MD Second Author: Eric Kallwitz, MD
Background: Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a life-threatening
syndrome. More than 50 drugs have been linked to DRESS syndrome and more commonly the main
culprit drugs have been anticonvulsents and allopurinol. We report a case of sulfasalazine-induce DRESS
syndrome treated with high dose corticosteroids and cessation of the offending medication.
Case Report: We report a 68 year old male patient who presented with a diffuse maculopapular rash
associated with eosinophilia of 17%, fever, and acute hepatitis at a large transplant hepatology center.
Three weeks prior to hospitalization the patient was started on sulfasalazine in addition to his chronic
hydroxycholorquine for psuedogout. On admission the patient was found to have elevated liver
associated enzymes which included AST 614, ALT 1584, INR of 1.6 and a total bilirubin of 18.1. The
working diagnosis of DRESS syndrome was made and by using the RegiSCAR's scoring system that grades
DRESS cases as "no," "possible," "probable, "or "definite" the diagnosis of sulfasalazine induce DRESS
syndrome was established. The patient received a course of high dose systemic corticosteroids and
managed with supportive care and cessation of sulfasalazine. His liver disease resoved uneventfully with
Discussion: Initial clinical presentations of DRESS syndrome can mimic other cutaneous reactions such as
toxic-epidermal necrolysis and Stevens-Johnson syndrome. But what differentiates DRESS syndrome
from other drug-induce reaction is the 2-6 week delayed skin reaction observed after initiation of the
offending medication as well as internal organ involvements and eosinophilia. The organ most
commonly affected is the liver and some patients that go untreated are associated with increase
morbidity and mortality, therefore early recognition of DRESS syndrome is paramount to initiate
treatment. Although the conditions rarity and variable presentations can make the diagnosis difficult,
the RegiSCAR scoring system offers guidance to define more accurately DRESS syndrome. Our patient
met criteria by scoring 5 points and falling in the probable/definite category. Conclusions: We present a
person with sulfasalazine induced DRESS syndrome that was promptly diagnosed and treated with
systemic steroids who recovered. This case report further supports previous case reports that it is
critical to swiftly diagnose and treat DRESS syndrome. DRESS syndrome has the potential to cause death
and because of its distinctie features clinicians should be made aware of this syndrome and the
RegiSCAR scoring system. Infectious causes should be ruled out promptly and any possible medications
should be stopped. However no clinical trials are available to provide a gold standard for the diagnosis of
DRESS syndrome and currently no standardized dosing or length of steroid treatment are available and
this identifies an area for future research.
Right Main Pulmonary Artery Thrombus After Type A Aortic Dissection Repair
First Author: Jae Cho, MD Second Author: Kimberly Brockenbrough, MD
Introduction: Aortic dissection is a life-threatening condition that requires emergent medical and
surgical treatment. Type A aortic dissection involves ascending aorta and needs emergent surgical repair
since these patients are at increased risk of complications such as aortic rupture, aortic regurgitation,
myocardial infarction, and cardiac tamponade. The major complications after type A aortic dissection
repair include recurrence of aortic dissection, aneurysm or pseudo-aneurysm formation, and leakage at
anastomosis site. We describe a case of right main pulmonary artery thrombus after type A aortic
dissection repair with graft.
Case description
A 50-year-old male was referred to the emergency department after acute pulmonary thrombus was
found on a CT chest after type A aortic dissection repair. He developed ascending aortic dissection 7
months ago and it was repaired surgically with Carbomedics aortic valve conduit with Teflon valve
stitches and BioGlue. After the surgical repair he was followed up with CT chest. He denied chest pain,
shortness of breath and syncope. His medications were metoprolol, albuterol inhaler, omeprazole,
morphine, simvastatin and warfarin. His vital signs were stable. Physical examination revealed clear
breath sounds without wheezing and crackles, and regular rate and rhythm without murmur. Complete
blood count was unremarkable. Comprehensive metabolic panel were within normal limits. He was
taking warfarin and the INR was 2.2. His CT chest with intravenous contrast showed 2.6 cm x 1.5 cm
thrombus in the right main pulmonary artery. Of note, the right main pulmonary artery was compressed
by the repaired ascending aortic structures. He was started with argatroban due to past history of
heparin-induced thrombocytopenia and his INR target was increased to between 2.5 and 3.5.
Discussion: Pulmonary artery thrombus is an extremely rare finding and has never been reported after
ascending aortic dissection repair up to the present time. After the aortic dissection repair, close
monitoring is required for the possible complications such as recurrence of aortic dissection, aneurysm
or pseudo-aneurysm formation, and leakage at anastomosis site. The right pulmonary artery is
susceptible to extrinsic compression by the distorted aortic structures after the surgical repair. The
preferred location of thrombus after ascending aortic dissection repair is the right main pulmonary
artery due to its close approximation. The possible mechanism of right main pulmonary artery thrombus
is the compression of the right main pulmonary artery by distorted aortic structure after the surgery and
altered blood flow dynamics in the pulmonary artery. The use of surgical glue as a possible implicating
factor should need future investigation.
Two Rare presentations of Wegener's granulomatosis-Digital gangrene and
Omental hemorrhage
First Author: Vishnu Vandana Palle, MD Second author: Mondira Sengupta, MD
Introduction : Wegener’s granulomatosis is a multisystem disorder of unknown etiology characterized
by aseptic, necrotizing, granulomatous inflammation of small vessels commonly affecting upper and
lower respiratory tract and kidneys. Although any organ can be involved, cutaneous involvement is less
common and gastrointestinal involvement is notably uncommon. We report a case of Wegener’s
presenting with digital gangrene and subsequently developing omental hemorrhage.
Case Presentation: A previously healthy 37 year old woman presented to her doctor with two days
duration of painful blue 1st and 5th toes of her right foot. She was sent home on acetaminophen after
an initial diagnosis of sprain based on X-ray. She presented to ER again, in a couple of days with painful
bluish-black discoloration of all her toes of her right foot and dry cough. Duplex Ultrasound study of legs
revealed blunted waveforms at all ten toes suggestive of small vessel disease below the level of ankle,
but no arterial or venous clots. A Chest X-ray and subsequent CT chest showed nodulocavitary lesions in
both the lungs. Laboratory work up showed positive serology for C-ANCA, anti-PR3 and Lupus
anticoagulant. Urinalysis was normal. A VATS biopsy of the lung lesions was suggestive of granulomatous
necrotizing inflammation of small vessels. A diagnosis of Wegener’s granulomatosis was made. Patient
was discharged on high dose prednisone and rituximab 375 mg/m2 weekly infusions for 4 cycles and
warfarin for blue toes. Cyclophosphamide was not given due to her concerns for fertility. Five days after
discharge, She presented to the ER second time with acute abdominal pain and hematemesis. On
examination, she was pale, hypotensive with rigid tender abdomen and dry gangrenous toes in her right
foot. An abdominal CT scan showed omental hemorrhage. Emergency laparotomy revealed mesenteric
ischemia with omental hemorrhage. A biopsy of mesentery showed vasculitis with acute inflammation in
the vessel wall. Her post operative course was uneventful and she was discharged on high dose
prednisone. Patient remained symptom free thereafter except for residual toe gangrene.
Discussion: This case illustrates two very rare manifestations of Wegener’s granulomatosis. Although
cutaneous manifestations may be a part of initial presentation in about 10 to 25 percent of cases, digital
gangrene is very rare and is limited only to a few case reports. The frequency of GI involvement in
Wegener’s granulomatosis is unestimated perhaps because it is frequently asymptomatic and may be
unrecognized. The literature mainly consists of individual case reports of patients with dramatic or
unusual GI presentations like in our case. The activity of skin lesions appears to closely parallel disease
activity in other organ systems and is indicative of active systemic disease.
First Author: Swati Gulati, MBBS SECOND AUTHOR: Shashvat Sukhal, MBBS THIRD AUTHOR : SHWETA
Introduction: Headache is one of the most common presenting complaints in the clinical setting, often
posing a diagnostic challenge when common etiologies have been investigated and ruled out. A high
index of suspicion for certain rare conditions is needed in patients with refractory symptoms. We
present a case of chronic refractory headaches in a middle aged woman that presented a diagnostic
challenge with a final diagnosis of a rare disorder, primary angiitis of CNS (PACNS), after a long and
frustrating course.
Case Report: A 59 year old woman presented with chronic debilitating frontal headaches of 8 months
duration with no focal neurologic complaints. The headaches were recurrent, lasting for hours, with
multiple daily episodes and no aggravating or relieving factors. She had no past medical history, no
medication or substance abuse. The physical and neurological exam was unremarkable except for
bilateral papilledema. Routine labs and CT of the brain were unremarkable. MRI of the brain showed
extensive pachymeningitis with meningeal thickening, and MRA of the brain was unremarkable. Three
lumbar punctures had a normal opening pressure, lymphocytic pleocytosis, polyclonal B-cells and
negative bacterial, viral and fungal cultures. HIV serology and systemic autoimmune workup were
negative including a whole body gallium scan. A possible diagnosis of CNS tuberculosis versus
cryptococcosis was made and she was started empirically on anti-tubercular therapy and fluconazole
which was discontinued after 2 weeks since her symptoms failed to improve. The possibility of
neurosarcoidosis was raised and she was started on prednisone. Her symptoms improved initially but
then headaches recurred and became steroid refractory with MRI showing worsening pachymeningitis.
A brain biopsy followed showing thickened dura and histopathology consistent with the granulomatous
pattern of PACNS. Her symptoms finally resolved with steroids and cyclophosphamide.
Discussion: In our patient with chronic recurrent headaches and non specific CNS analysis and
radiological findings, the initial differentials for this presentation were neurosarcoidosis, tuberculosis,
and CNS lymphoma. However her headaches remained refractory to steroids, anti-fungals and antitubercular therapy. With a normal MRA, a CSF analysis revealing aseptic meningitis was the only subtle
clue to the presence of vasculitis. An autoimmune panel was negative, suggesting that vascular
inflammation was confined to the neurovascular bed and a diagnosis of PACNS was made after brain
biopsy. CNS vasculitis involving the small/medium vascular bed restricted to the spinal cord and brain, in
the absence of systemic involvement, is known as PACNS. It is a rare disease with an incidence of 2.4
cases per 1,000,000. It is more predominant in males and can have a wide range of clinical and
radiological features, mimicking various pathologies. Diagnosis of PACNS requires the presence of three
major criteria which include acquired unexplained neurologic or psychiatric deficit, presence of classic
angiographic or histopathological findings of CNS angiitis and the absence of systemic vasculitis. Brain
biopsy remains the gold standard for diagnosis but may be negative due to patchy nature of the disease.
Infections in asplenic patients
First Author: Lokesh R Shahani, MD, MPH Nancy Khardori, MD, PhD
Background: Asplenic patients are prone to overwhelming infections due to encapsulated organisms.
Infection in such patients can progress rapidly and be fatal. The risk of infection is lifelong but highest in
the first two years of splenectomy.
Case report: We report a 62 year old male who presented to the emergency room with complaints of
fever and weakness for the past day. His past history was significant for splenectomy 40 years ago after
a motor vehicle accident. The patient worked as a mail man and had a dog as his pet. The patient on
examination had signs of dehydration and had some animal bite and scratch marks on his lower
extremity. The patient initial blood cultures were positive for gram negative rods, but no organism was
identified. Over the next few days the patient progressed to multi-organ system failure. The infectious
disease service was consulted and Capnocytophaga canimorsus was the suspected organism. Antibiotics
tailored to the particular organism namely piperacillin / tazobactam were continued for 14 days. The
patient had good response to the above treatment and showed clinical improvement. The patient’s
blood cultures finally grew Capnocytophaga canimorsus on day 20 for which the patient had already
been treated with prior clinical judgement.
Conclusion: Capnocytophaga canimorsus are normal inhabitants of the oral cavity of dogs and cats.
Splenectomized patients are more prone to develop sepsis with disseminated intravascular
coagulopathy (DIC) when infected with this particular organism. Capnocytophaga canimorsus is a
fastidious organism and at times does not easily grow in culture media. Physicians should be aware of
this organism in the setting of sepsis in asplenic patient and use appropriate antibiotics till further
results are obtained. Further patients should be educated about their risks of infections and both
immunoprohylaxis and chemoprophylaxis should be used for prevention of infection in asplenic
Pulmonary Blastomycosis: A Challenging Diagnosis In Difficult Scenario
First Author: Kovid Trivedi,MBBS Other Authors: Jose A.Paul,MD Hosam Hakim,MD Veena B.Iyer,MBBS
Hasnain S.Bawaadam,MD MPH Ashok Fulambarker,MD Ahmet S.Copur,MD Rashid Nadeem, MD
Introduction: Pulmonary Blastomycosis, in spite of being a common pyo-granulomatous fungal
infection in the Midwest, is not an easy diagnosis. Because of varied clinical presentation, it requires
high degree of clinical suspicion in order to initiate the diagnostic process.
Case: A 51year old male with history of type2 diabetes mellitus, hepatitis C, obstructive sleep apnea,
depression and post traumatic stress disorder presented with complains of acute left sided chest pain.
Patient reported shortness of breath for last 10days with reducing exercise tolerance. Low grade fever
and non-productive cough were present. Review of systems was negative. Physical examination was
unremarkable. On admission, acute coronary syndrome and pulmonary embolism were ruled out. CT
scan of thorax showed right lower lobe infiltrate with multiple nodular infiltrates all over the lung fields.
CBC revealed leucocytosis of 14000 with 76% neutrophils. Sputum and blood cultures were negative.
Levofloxacin was started for community acquired pneumonia. Patient remained afebrile and clinically
improved over next 2days with reduced leucocyte counts. Later, patient clinically worsened and repeat
chest X-ray revealed new left lower lobe infiltrate in addition to previous findings. PiperacillinTazobactam was added for broader coverage. Patient did not improve clinically, which led to
consideration of other diagnoses. c-ANCA and p-ANCA were negative. Flexible bronchoscopy was done
with transbronchial biopsy, washing, brushing and lavage from right upper lobe posterior segment and
right lower lobe posterior basal segment to rule out tuberculosis, fungal infection and malignancy. The
results were non-conclusive. Lesions were not amenable to CTguided biopsy and patient continued to
have a fluctuating clinical course. Patient was then subjected to VATS of right upper and right lower lobe
with wedge biopsy. Biopsy specimen showed granulomatous necrotizing inflammation with broad based
budding yeast in all specimens, confirming diagnosis of Blastomycosis.
Discussion: Caused by Blastomyces dermatitidis, Blastomycosis can affect any organ of the body, but is
most common in lungs. Symptomatic infection occurs in less than 50%of patients. It is known as great
masquerader as it can present as variety of acute or chronic presentations. Lobar consolidation to
miliary infiltrates to masses may be present in lungs and it compels to rule out other threatening causes
such as tuberculosis or malignancy. Sputum culture has a yield of 76%with 1specimen and upto 86%per
patient for diagnosis. Bronchoscopy has been found to be diagnostic in 92%cases. Our patient had
multiple pulmonary nodules with unknown duration of existence. Sputum culture and bronchoscopy
were not diagnostic and CTguided biopsy could not be done. Invasive biopsy was required in order to
establish a common diagnosis. Cases like this can be a diagnostic challenge.
First Author: Suneel Kumar, MD Shobha Shahani, MD James Kumar, MD
Introduction: Dyspnea is a very common presenting complaint to emergency departments (EDs) in US,
accounting for 3.5% of visits to EDs. Diseases involving multiple organ systems can present as dyspnea. A
detailed history with a comprehensive review of systems is essential in unraveling the underlying cause
of dyspnea.
Case Presentation: A 77 year old obese white male presents with episodic dyspnea and chest tightness.
He has had similar symptoms several times in the past 12 months resulting in multiple ED visits. A
detailed review of systems revealed abdominal bloating, gas and altered bowel habits (initially diarrhea
and then constipation) for at least 2 years. Lately this has been associated with hot flashes and sweats.
He was recently diagnosed with fructose intolerance. He developed acute anemia with an unremarkable
upper and lower gastrointestinal endoscopy. He also has coronary artery disease with recent coronary
stenting. Physical exam was unremarkable. Oxygen saturation was 98% on room air. Initial laboratory
evaluations were unremarkable except for acute anemia. He underwent Video Capsule Endoscopy for
further work up of acute drop in hemoglobin, which showed dilation of ileum and suspicious stricture
distally. An exploratory laparotomy revealed a small bowel mass which was resected. Pathology
revealed low-grade Carcinoid tumor with local nodal and mesenteric metastasis. Urinary 5HIAA was
normal, serum chromogranin A was high. OctreoScan was unremarkable for any other metastases. The
patient has been started on IV octreotide for symptomatic relief. He will be followed with repeat 5HIAA
and chromogranin A levels. The patient experienced significant symptomatic relief with octreotide.
Carcinoid is a rare neuroendocrine tumor with annual incidence rate of 4.7/100,000. Gastrointestinal
tract is the most common site (55%). Carcinoid syndrome is the symptom complex mediated by various
humoral factors elaborated by some carcinoid tumors. It is most commonly associated with mid-gut
carcinoids. And it implies a metastatic tumor in majority of cases. Most commonly, it presents with
episodic cutaneous flushing, venous telangiectasia and diarrhea. About 10 to 20% of patients with
carcinoid syndrome can present with dyspnea. Although rare, but carcinoid syndrome should be
considered in differential of dyspnea when associated with above constellation of symptoms. The
octreotide suppresses the secretion of serotonin and other peptides; there by controlling the associated
Hypercalcemia, A harbinger of pathologic disequilibrium! The Butterfly effect?
First Author: Snigdha Kola, MBBS Second Author: James Kumar,MD
Introduction: Calcium is essential for bone formation and neuromuscular functions. It is regulated by a
complex interplay of parathyroid hormone (PTH) and Calcitriol (1, 25 dihydroxy Vitamin D) acting on
various organ systems. A serum calcium >10.3 mg/ dl with a normal serum albumin defines
hypercalcemia. The most common cause of hypercalcemia in ambulatory patients is primary
hyperparathyroidism. However, in inpatients, underlying malignancy is more commonly prevalent.
Case Presentation : A 55 year old gentleman was admitted with complaints of progressive lower
extremity weakness with consistent physical examination findings. His weakness had previously been
attributed to mechanical back problems. Initial laboratory data revealed hypercalcemia. Further work up
revealed a suppression of intact PTH and normal renal function. Serum phosphorus was elevated and
PTHrP (Parathyroid hormone related peptide) undetectable. Calcitriol level was found to be 53 pg/ml (
reference range 18-61 pg/ml) in a setting of calcium level of 11 mg/dl. Computerized Tomography (CT)
of the thoracolumbar spine showed right sided paraspinous mass at T12-L1 which extended into the
neuroforamina. Biopsy revealed diffuse large B-cell lymphoma. An aggressive treatment regimen with
steroids, radiation therapy and chemotherapy showed improvement in calcium levels, however,
patient’s weakness worsened and succumbed to the disease
Conclusion: Hypercalcemia and neuromuscular weakness warrants a detailed diagnostic evaluation.
Hypercalcemia should be considered pathological unless proven otherwise.
Elevated calcitriol is a common occurrence in Lymphoma, however elevated calcitriol being the primary
mechanism for hypercalcemia is rare, seen in 8-10% of patients with B cell lymphoma. Elevated calcitriol
levels is mechanism more specific for B cell lymphomas while PTHrP is associated with T cell.
Speechless Extubation!-A case report of bilateral hypoglossal nerve paralysis
following extubation.
First Author: Vaishnavy Bhaskaruni, MBBS Sangeeta Juloori, M.D., Sajan Thomas, M.D., Abhinandan
Pakanati, M.D.
Introduction: Complications of intubation are common. In a series of over 3400 emergent intubations,
the incidence of difficult intubations was reported to be around 10%. Cranial nerve injury following
intubation is rare. Most reports describe a combination of hypoglossal nerve and recurrent laryngeal
nerve paralysis (Tapia’s syndrome). Cases that describe isolated bilateral hypoglossal paralysis are
exceedingly rare.
Case Presentation: A 63 year old morbidly obese lady with no known medical history presented
emergently with worsening shortness of breath. She had a CT scan of the abdomen, which showed free
intra-peritoneal air. Due to her short neck and morbid obesity, intubation was difficult. Following
intubation, an emergent exploratory laprotomy was done. After a complicated and prolonged postoperative course, she was extubated. She was then found to have severe dysarthria, which did not
resolve even after 48 hours. She was noted to have complete bilateral paralysis of the tongue. Cranial
nerves 2 to 11 were intact. She had no other focal neurological deficit. CT scan of the head was normal.
A presumptive diagnosis of bilateral hypoglossal nerve paralysis was made. The cause was most likely
traumatic intubation.
Discussion: Isolated bilateral hypoglossal nerve paralysis following intubation is exceedingly rare, having
been described only a handful of times in medical literature. It can occur following oro-tracheal
intubation, laryngeal mask airway or bronchoscopy. The risk factors include traumatic/difficult
intubation, multiple intubations, prolonged intubation time and hyperextension of the neck during
intubation. While the definitive pathophysiology is not known, a popular theory is that mechanical
alteration during intubation leads to axonotmesis-thereby leading to nerve injury and presenting as
paralysis. The cause of nerve injury can also be attributed to neuropathy provoked by compression
following cuff inflation within the larynx. It has also been postulated that nerve damage can occur due to
neck hyper-extension during a diffcult intubation. One case report suggests that prognosis is favorable
as long as the continuity of the nerve sheath is maintained. This complication of intubation (bilateral
hypoglossal nerve paralysis) can potentially be avoided by paying attention to correct positioning of the
head during surgery, avoiding hyper-extension, especially if prolonged intubation is anticipated. It is
important to recognize that intubation can cause hypoglossal nerve injury, presenting as unilateral or
bilateral tongue paralysis.
Coma: Hyperthyroid or Hypothyroid?
First Author: Pakhadi Buddhadev,MD, second author: Mihir Shah,MD, Mehul Vora,MD.
Introduction: Thyroid storm is a severe form of thyrotoxicosis that usually presents with tachycardia,
tremors, weight loss, fever, seizures, vomiting, diarrhea, arrhythmia or coma. If not treated aggressively,
it can be rapidly fatal. It can also present with atypical features like apathy and coma. We present such a
case for its rare presentation and management.
Case Presentation: A 75 year old gentleman presented to the ER with cough and fever. He complained
of feeling weak and depressed for 2 weeks. Past medical history was significant for Type 2 DM, HTN,
CHF, pacemaker placement. He had no history of thyroid disease in the past. Within 2 hours of being
admitted, he became incoherent and confused. He was transferred to the ICU for evaluation of
encephalopathy. In a few minutes he slipped into coma and was intubated to protect his airways. His
pulse was 124/min, regular, BP 138/68mmHg, RR 24/min, temperature 100.4F, and saturating at 98%.
On exam he was sweating diffusely, pupils were reactive to light, had prominent thyroid gland, heart,
lung and abdomen exam was normal. No tremors or increased tendon reflex. His labs showed Liver and
Renal Chemistry was normal. Hgb 10.5gm/dl, WBC 5.8, HgA1C 6.7 %, BNP was 2032pg/ml, TSH
<0.005uIU/ml (0.4 – 5.4), Free T4 5.36ng/dl(0.70 – 2.0), T4 19uIU(4.6 to 12.0 µg/dL), T3 407.5 ng/dl (80
to 200 ng/dL), Free T3 14.1pg/ml (1.70 – 4.20), TSI 129 %(<130%), TPO antibody 14 IU/ml (<35), CT Head
showing multiple old small infarcts bilaterally, CSF exam normal, Cortisol levels normal, EEG was
suggestive of Encephalopathy, USG Thyroid showed diffuse thyromegaly. A diagnosis of thyroid storm
was made and patient was started on methimazole, Lugol’s iodine, propranolol and methylprednisone.
He gradually improved, was coherent, back to baseline in a week and discharged. On follow up I123
uptake scan was done which showed 70 % generalized uptake.
Discussion: Apathetic thyrotoxicosis is an exceedingly rare presentation of thyroid storm. The clinical
picture is of apathy rather than hyperactivity. Cardiovascular signs may be present. Our search revealed
case reports of hyperthyroidism with apathy mostly in the Elderly. Our case is a little unusual since we
did not have elevated TSI or TPO levels. Absence of typical signs of hyperthyroidism like hyperkinetic
motor activity, hand tremors, ocular signs may cause the diagnosis to be missed early in the disease
process. Testing for thyroid functions as a routine for all patients presenting with altered mental status
may be helpful. It is important to emphasize this point because these people under usual circumstances
do not appear ill, but under stress can quickly and quietly sink into coma.
Pulmonary Nocardiosis: An Opportunistic Infection Not to be Missed
First Author: Roel Conrad E Jamis, MD
Introduction: Patients who are admitted to the hospital with respiratory symptoms and abnormal chest
imaging findings are common. Physicians usually keep a short list of differential diagnoses. The possible
etiologies increases dramatically in the setting of cancer and immunocompromised states. Atypical
causes of pneumonia-like symptoms must be considered in the setting of immunosuppression and
malignancy, especially if symptoms are recurrent despite treatment. This case is notable because prior
non-diagnostic finding on bronchoscopy needs to be verified by a repeat diagnostic procedure in light of
persistent symptoms and worsening imaging findings. A delay of repeating an invasive but potentially
diagnostic procedure could spell the difference between life and death for the patient.
Case: A 77 year-old man was admitted for left-sided chest pain. He had a history of chronic
lymphoblastic leukemia and had received prior chemotherapy. He was also admitted twice in the
preceding four months because of shortness of breath and pulmonary infiltrates on chest x-ray. Further
evaluation done at the time, including bronchoscopy with bronchial alveolar lavage, was non-diagnostic,
prompting empiric treatment with high-dose trimethoprim-sulfamethoxazole and tapering steroids for
possible Pneumocysitis jiroveci pneumonia, and amphotericin for possible fungal pneumonia. During his
second admission, open-lung biopsy was offered as an option, but the patient refused to undergo the
said procedure.
On admission, vital signs were stable. No tenderness was elicited on palpation of the back, and breath
sounds were clear. Laboratory studies were significant for mild leukopenia. A CT scan of the chest
revealed a rapidly enlarging nodule on the left lower lung, which increased 1.5 cm in size in less than 2
weeks. The patient was placed on empiric meropenem and amphotericin. Blood cultures were sterile.
Tests for fungal antigens were negative. A CT-guided lung biopsy was done, which revealed necrotizing
granulomatous inflammation of the lung parenchyma. Cultures of the aspirate later grew Nocardia
wallacei. The patient’s antibiotics were later changed to trimethoprim-sulfamethoxazole and amikacin.
His symptoms resolved and patient was discharged, completing his intravenous antibiotic regimen of 4
Discussion: Nocardiosis is a rare infection caused by a gram-positive aerobic actinomycetes of the genus
Nocardia. Nocardiosis disseminates to multiple organs, but the lungs are the primary site of Nocardial
infection. Symptoms are nonspecific, and diagnosis is established by isolation and identification of the
organism from a clinical specimen. Antibiotics used in treatment include trimethoprimsulfamethoxazole, amikacin, imipenem, and third-generation cephalosporins such as ceftriaxone and
cefotaxime. Poor outcomes are associated with a delay in diagnosis, thus empiric therapy in suspicious
cases, as well as timely diagnosis aided by careful history-taking, is essential.
An uncommon cause of lytic lesions of the skull
First Author: Abhijai Singh, MD Second Author: Subhash Varma Third author: Vikas suri
Introduction: Bone involvement is an uncommon extrapulmonary manifestation of sarcoidosis. Even
more infrequent are punched out lytic lesions in the calvarium at presentation in the absence of other
multisystem manifestations.
Case description: A 65 year old Indian lady presented with history of two months history of xerostomia,
polyuria, fatigue and anorexia. Exam was pertinent for an obese lady (BMI-30.81 kg/m2) with significant
generalized lymphadenopathy and hepatomegaly. Laboratory evaluation revealed a normocytic
normochromic anemia (Hgb of 10.1g/dl), hypercalcemia (S.Ca2+ 16.3mg/dl) with normal phosphorus
(3.9mg/dl) and normal renal function. Serum alkaline phosphatase and a 24 hr urinary
calcium/phosphorus assay were normal. iPTH levels were normal and PTHrp levels were undetectable.
CECT abdomen was significant for hepatomegaly, periportal and retroperitoneal lymphadenopathy with
bilateral nephrolithiasis without hydroureteronephrosis. A skeletal survey revealed extensive osteolytic
lesions in the skull, phalanges with significant uptake on Ga67 citrate bone scan. Serum and urine protein
electrophoresis, immunofixation, and PPD were negative.
Cervical lymph node biopsy and a bone marrow aspiration revealed non caseating granulomas. Patient
was started on 1mg/kg prednisone with a diagnosis of stage II pulmonary sarcoidosis with
extrapulmonary manifestations. During a follow-up of 6 months, patient achieved normocalcemia,
normal hematocrit with resolution of systemic symptoms
Discussion: Sarcoidosis of the bone occurs in 5-15% of the patients. Mayock et al described an incidence
of 14% in 145 patients of sarcoidosis. Small tubular bones are most frequently involved, especially the
middle and the distal phalanges of the hands and the feet. The long bones, vertebrae and the skull are
rarely involved with less than 40 cases reported in literature. Cutaneous manifestations are commonly
reported in these patients unlike the index case
Three predominant patterns of bone involvement have been reported: 1) Lytic - rounded cortical or
medullary lesions of variable size that left a “punched out” cyst as the residual lesion 2) Permeative progressive cortical tunnelling with remodelling of trabecular and cortical structure and 3) Destructive rapid progression and pathological fractures and concomitant articular involvement. Elevated levels of 1,
25(OH) 2 Vitamin D, various cytokines elaborated by the inflammatory cells in the granuloma, and a
locally produced osteoclastic factor have all been implicated in the pathophysiology. Role of steroids is
controversial in treatment of the bone lesions. It is particularly difficult to assess the significance of
exogenous steroids in the resolution of calvarial sarcoidosis due to spontaneous improvement reported
in literature.
This case reiterates the need for awareness and the importance to recognize that sarcoidosis as a close
differential of TB in immigrants from emerging nations.
How complete is your physical exam?
First Author: Dima Dandachi, MD Afsin Oktay, MD Harvey Friedman, MD
Introduction: 25-year-old man was brought to the ED with sudden onset of loss of consciousness, jerky
limb movements, upward deviation of the eyes and urinary incontinence. Information was provided by
the family. He had one-month history of progressive confusion, visual and auditory hallucinations, and
memory loss. He recently had had three unwitnessed motor-vehicle accidents without any injuries.
Case Presentation: Past medical history was insignificant except diaphragmatic hernia repair and viral
upper respiratory infection two months back. He had been recently started on olanzapine and
fluoexetine but the symptoms didn’t improve. The sexual history was unknown, family history was
irrelevant and no known allergies. He was a smoker (6 pack-year cigarettes) with no report of alcohol or
illegal drug use. On physical exam, vitals were stable. He was awake but uncooperative and confused.
Chest, heart and abdominal examinations were unremarkale. Neurological exam was positive for altered
mental status. Initial laboratory workup showed normal CBC and BMP. Urine toxicology analysis was
negative. He was admitted to the hospital. CSF analysis after lumbar puncture revealed elevated WBC,
55 cells/µL (lymphocytes 92%); normal glucose, 48 mg/dL (serum glucose, 80 mg/dL); and elevated
protein, 92 mg/dL. Further workup for viral encephalitis, bacterial meningitis, tuberculosis, HIV, syphilis,
lyme disease and vasculitis were all negative. EEG showed diffuse slowing of the background activity. He
had T1 hypoentense lesions in peri-ventricular white and grey matter of temporal lobes bilaterally on
MRI-brain. He was initially kept on acyclovir until HSV PCR came out negative. The hospital course was
complicated by worsening confusion and aspiration which led to respiratory failure, intubation and
mechanical ventilation. CT abdomen was performed and revealed large heterogeneous retroperitoneal
infra-renal mass abutting the aorta and IVC. At that point genital exam was performed and enlargement
of left scrotum with hard mass was found. Ultrasound testicle was suggestive of malignancy. AFP, ß-HCG
levels were normal. He underwent FNA of the right para-aortic mass. Diffuse large B- cell lymphoma
diagnosis was confirmed with pathology evaluation. His mental status change was attributed to paraneoplastic limbic encephalitis in the absence of other explanations. He was started on chemotherapy
and his mental status progressively returned to baseline.
Discussion: Para-neoplastic limbic encephalitis is an inflammatory and degenerative disorder associated
with neoplasms of lungs, testis and lymphomas. It manifests with sub-acute onset of memory loss,
seizures and psychiatric symptoms. Diagnosis usually depends on clinical suspicion since EEG and CSF
analysis show non-specific abnormalities and no pathognomonic MRI findings exist. Limbic encephalitis
can reverse with treatment of associated neoplasm. In our case, an accurate genital examination at the
admission would have led us to the diagnosis earlier and saved the patient many tests.
Most common form of rare coagulation factor deficiencies
First Author: Muhammad Toor, MD,MBBS. Second Author: Sabeen Zeb, MD.
Introduction: Acute renal failure is one of the common presentations seen in post operative patients.
Renal hypo perfusion secondary to blood loss usually precipitates it. During preoperative evaluation of
the patients with subtle abnormalities in coagulation indices like activated partial thromboplastin time
(aPTT) which measures the intrinsic pathway, prothrombin time/International normalized ratio (PT/INR)
which measures the extrinsic pathway and platelet count should be taken seriously and warrants further
investigations to prevent post operative complications of blood loss and acute renal failure.
Case Presentation: A 74 year old female presented with the complaint of left hip pain after a fall. Plain
x-rays confirmed the diagnosis of proximal femur fracture. Post operatively she had blood loss from the
surgical site to an extent that she developed renal hypo perfusion and acute renal failure. When
evaluation of patient was started we came across a chronically elevated INR in range of 1.3- 1.4 (0.91.1). She denied any history of bleeding disorder in her family or any history of excessive bleeding in the
past. She was not on any anticoagulation, antibiotics and did not have any liver problems. Detailed
investigations in to her coagulation profile revealed normal coagulation indices except prolonged PT/INR
and factor VII deficiency. She was started on FFP’s and her bleeding stopped. She was resuscitated with
blood and intravenous fluid and her renal functions responded well and she was discharged in a stable
Discussion: Factor VII deficiency is the most common among the rare autosomal recessive coagulation
disorders worldwide. The main role of factor VII is to initiate the process of coagulation in conjunction
with tissue factor (TF/factor III). The very short half-life of factor VII (four to six hours) makes it difficult
to use FFP without causing volume overload though in our case she needed volume. A specific assay for
factor VII, using known factor VII–deficient plasma, is required to confirm the diagnosis. Recombinant
factor VIIa (rFVIIa) is the most common replacement therapy for congenital factor VII deficiency.
However, unlike haemophilia patients for whom treatment protocols are straight forward, in
asymptomatic factor VII deficiency patients it is still debatable. Therefore in such patients detailed
preoperative evaluation is necessary to decide about therapeutic administration of rFVIIa to prevent
postoperative blood loss and end organ damage
The Perilous Pearl
First Author: Shobha Shahani, MD Suneel Kumar, MD James Kumar, MD
Introduction: Stroke is the third most common cause of death and a leading cause of serious long term
disability in the US. Approximately 80% of strokes are ischemic and cardio-embolism is responsible for
20% of ischemic strokes. Cardiac Papillary Fibroelastoma (CPF) is a rare cause of cardio-embolic stroke.
The incidence of primary cardiac tumors is less than 0.1% and CPF is the second most common primary
cardiac tumor in adults. It has a very high embolic potential.
Case Presentation: A 41 year old Caucasian female was evaluated in an outpatient clinic 4 hours after
her friend observed that she had slurred speech and facial droop for 30-40 seconds that spontaneously
resolved. She denied any other focal motor or sensory symptoms, headache, visual changes, loss of
consciousness or fall. She did not have any past medical or surgical history. She was not on any
medication. She had 10 pack years smoking history, drank a glass of wine every night, and never used
any illicit drug. Her family history was significant for diabetes, hypertension and premature coronary
artery disease in first degree relatives. The physical examination was unremarkable except for blood
pressure of 160/100. She refused hospitalization, but agreed to outpatient work up. She was started on
Aspirin and Simvastatin. Initial stroke work up including CBC, CMP, lipid panel, coagulation studies,
homocysteine, RPR, ESR, ANA was unremarkable. Brain MRI showed several small subacute enhancing
infarcts in the left inferior frontal gyrus and left anterior corona radiata. A subsequent transesophageal
echocardiogram (TEE) revealed an echogenic mobile structure of 0.6 x 0.5 cm attached to the aortic
valve over the left coronary cusp consistent with CPF. Patient underwent excision of the aortic valve
mass. Histopathology was consistent with CPF.
Discussion: CPF is a rare cardiac tumor which, although benign in nature, can lead to devastating
consequences due to its strategic position and high embolic potential. The most common manifestations
are transient ischemic attack, stroke, myocardial infarction, heart failure, syncope and sudden cardiac
death. Tumor mobility is the only independent predictor of CPF-related death or non-fatal embolization.
The most commonly used modality for making initial presumptive diagnosis is TEE. The final diagnosis is
by histopathology.
Conclusion: In the young patients with stroke, who lack traditional stroke risk factors, further work up
with cardiac imaging to rule out cardio-embolism is appropriate. Use of transesophageal
echocardiogram can lead to timely diagnosis of cardiac tumors with high embolic potential such as CPF.
Surgical resection of CPF is justified in patients who are symptomatic or have mobile tumor.
Thymoma Can Be As Nasty As This!
First Author: Salih Samo, MD Other authors: Muhammed Sherid MD, Samian Sulaiman MD, Husein
Husein MD, Hani Snounou MD, Shahriar Dadkhah MD, Harvey Friedman MD
Learning objectives:
1. Malignant thymoma, although rare, can present as a mediastinal mass.
2. Invasive thymoma should be always taken into consideration when patient has mediastinal mass
and constitutional symptoms.
Methods: We report a case of invasive malignant thymoma classified as stage III-IVa according to
Masaoka’s staging system.
Case Presentation: A 70 year old F presented with fever, SOB and chest pain. CXR showed consolidation
at the right lung base and was also suspicious for a mass in the right perihilar area. She was started on
antibiotics for pneumonia. CT chest showed a large mass measured up to 7.8 x 5.8 x 10 cm in the
anterior right hemithorax. Biopsy of the mediastinal mass showed a neoplastic proliferation composed
of a mixture of lymphocytes and large keratin-positive epithelial cells with fibrous bands, consistent with
thymoma. The immunohistochemical findings supported the diagnosis of low grade malignant
thymoma. Flow cytometry showed no immunophenotypic evidence of lymphoma.
Subsequently, the patient underwent surgical resection of the mass. Findings at time of operation were
consistent with a large tumor which was encircling the innominate vein and the right phrenic nerve. The
innominate vein was sacrificed during the procedure. Further examination grossly of the innominate
vein suggested invasion. 10 days later, she returned to the hospital with a complaint of left upper
extremity swelling and SOB. Doppler study showed left internal jugular and subclavian vein thrombus
and patient was started on anticoagulation.
15 days later patient was admitted again for complaint of SOB and was found to have a significant
pericardial effusion with impending tamponade by echocardiography. She underwent pericardial
window. Patient was dyspneic since after the surgery and was intubated eventually. She had cardiac
arrest and expired secondary to hypotension, hypoxia, and metabolic acidosis.
Discussion: Malignant thymoma is an indolent tumor arising from the thymic epithelial cells. These
tumor cells spread via regional metastasis or invade surrounding structures, including the pleural space.
Most patients with invasive thymoma present with constitutional symptoms, including fever, night
sweats, and weight loss, in addition to symptoms related to local compressive mass effects, such as
chest pain, dyspnea, dysphagia, and cough. Radiographic appearance and tissue samples are very
important in determining the diagnosis as well as the stage of the disease.
First Author: Sangeeta Juloori, M.D., Second Authors: Vaishnavy Bhaskaruni M.D., Abhinandhan Pakanati
M.D., Sajan Thomas M.D.
INTRODUCTION: May Thurner syndrome is caused when the left iliac vein is compressed by the right
iliac artery, which increases the risk of deep vein thrombosis in the left lower extremity. We are
reporting a patient who presented with isolated left lower extremity pain and swelling.
Case Presentation: A 47 year old female presented to the emergency room with left lower extremity
pain and swelling for 3 days. Pain started in the left gluteal region and was radiating to the left lower
extremity. There was no history of trauma, fever, chills, significant immobility and shortness of breath or
chest pain. Ultrasound venous doppler of left lower extremity showed occlusive thrombus in left
common femoral vein, and partially occlusive thrombus in the proximal left femoral vein, consistent
with Deep vein thrombosis. CT scan of pelvis and abdomen with contrast showed occlusive thrombus in
the left common iliac vein extending into the visualized portion of the left common femoral vein,
compatible with deep venous thrombosis. In addition, it was noted that the left common femoral vein
was compressed by the right common iliac artery which was consistent with May Thurner syndrome.
DISCUSSION: May Thurner syndrome is more common in women compared to men. Patients with this
syndrome can present with pain, swelling in the leg, increased warmth in the leg, redness or
discoloration of the skin, or venous engorgement in the lower extremity. The diagnosis of this syndrome
is based on combined evidence of clinical presentation of left lower extremity swelling or pain in
association with radiologic evidence of compression. Diagnostic modalities for this syndrome include
ultrasound venous doppler , helical abdominal computed tomography, CT venography and magnetic
resonance venography . Typical management of a patient with May Thurner syndrome includes
anticoagulation, catheter-directed thrombolytic therapy followed by angioplasty and stenting. In
patients with contraindications or with recurrent DVT on adequate anticoagulation therapy, IVC filters
should be placed to prevent pulmonary embolism.
Severe Cobalamin Deficiency: A case illustrating the diagnostic pitfalls
First Author: Naseem A Ghazanfari, MD Second authors: Asmeret Demissie MD, Summi Pargal MD,
Mossab Silk MD, Edward Poje MD, Robert Mocharnuk MD
Introduction: Severe vitamin B12 deficiency is one of the most curable causes of life-threatening anemia
and pancytopenia. Most clinicians will readily make the diagnosis if the mean red blood cell volume
(MCV) is increased. However, patients with hemolytic anemia associated with B12 deficiency can
present with normal or low MCVs, obscuring the diagnosis and delaying treatment.
Case Description: A 52-year-old African American female was admitted to hospital with a one week
history of fatigue and exertional dyspnea. She denied any history of abnormal bleeding but
acknowledged a remote history of B12 deficiency for which she received monthly injections. However,
she was lost to follow up for over a decade. Her family history was unremarkable. Abnormal physical
findings included slight tachycardia and mild conjunctival pallor. Lab data revealed a hemoglobin of 6.0
g/dL, MCV 83fl, RDW 32.2, WBC count 4,500/mm3, and platelets 54,000/mm3. Iron studies and thyroid
function tests were normal. Her corrected reticulocyte count was 0.8%. Other significant lab data
included an elevated indirect bilirubin of 2.1mg/dL, an elevated LDH of 3,651 IU/L, low serum
haptoglobin (<6mg/dL ) and a negative direct antiglobulin test.
Peripheral blood smear review revealed hypersegmented neutrophils , numerous megaloblasts and
multiple schistocytes . A serum B12 level was 27pg/ml, (normal range 200 – 900 pg/mL) , a serum
homocysteine level was 37.7 uMol/L, and serum folate was normal. The patient was transfused with 4
units of packed red blood cells and started on daily intramuscular B12 injections. Her fatigue and
exertional dyspnea improved almost immediately. Her hemoglobin remained stable throughout her fiveday hospital stay, without requiring further transfusions. Later, a normal hemoglobin electrophoresis
ruled out thalassemia and a positive anti-intrinsic factor antibody confirmed the diagnosis of pernicious
Discussion: Red cell fragmentation and marked abnormalities in the size and shape of RBCs have been
described in severe megaloblastic anemia, but may not be widely recognized by clinicians. It is well
known that coexisting iron deficiency or thalassemia can mask macrocytosis. However, the presence of
both megaloblasts and schistocytes can result in normal MCVs since the mean corpuscular volume is
calculated using a RBC volume histogram that averages all red cells present in the sample. The diagnosis
in our patient’s case was complicated by two, less frequent manifestations of cobalamin deficiency:
hemolytic anemia and a normal MCV.
The clues that led to the diagnosis of B12 deficiency included her past medical history, a low
reticulocyte count in the presence of hemolysis indicating an abnormal bone marrow response to severe
anemia, and an unusually high RDW despite normal MCV. The latter prompted a review of the
peripheral blood smear, revealing a marked variation in RBC size, ranging from macrocytes to small
fragmented cells, secondary to intramedullary hemolysis.
A puzzling ascites in a blind man on hemodialysis
First Author: Radhika Kothakota MD Natasa L Margeta MD, Dinesh Gaddam MD Department of Internal
medicine, John.H.Stroger Hospital of Cook County
Introduction: Nephrogenic ascites is an extremely rare type of refractory ascites of unknown incidence
and unclear etiology. It is mostly seen in end stage renal disease patients undergoing chronic dialysis.
Case Presentation: We present a case of a 68 year old legally blind, Hispanic gentleman with past
medical history of hypertension, diabetes, systolic heart failure and end stage renal disease on chronic
hemodialysis for past three years. He was admitted to our hospital for shortness of breath due to
increasing abdominal girth of one month duration. Previously, he was on peritoneal dialysis for many
years and was hospitalized many times in the past for recurrent bacterial peritonitis. Due to recurrent
infections, he was switched to hemodialysis. On admission, he denied constitutional and cardiac
symptoms. His vital signs were normal. On physical exam, he had tense, distended abdomen with
positive fluid wave and no signs of liver cirrhosis. His cardiac exam was unremarkable. Large volume
paracentesis was performed and results were consistent with low SAAG ascites. Computed tomography
of abdomen showed omental nodularity suspicious for peritoneal carcinomatosis. Patient underwent
extensive diagnostic evaluation including laparoscopic assisted peritoneal biopsy. Main differential
etiology of low SAAG ascites including tuberculosis and malignancy were ruled out by multiple negative
cytologies on peritoneal fluid for malignant cells and negative peritoneal biopsy for caseous granulomas
and malignancy. His history, laboratory results and peritoneal fluid analysis were not diagnostic of acute
pancreatitis, nephrotic syndrome, biliary or bowel obstruction and connective tissue disease related
serositis as a possible etiology of low SAAG ascites. Patient was evaluated by nephrologists as well and
after extensive evaluation consensus, a reasonable diagnosis of nephrogenic ascites was made.
Discussion: This case particularly illustrates extensive work up needed for evaluation of new onset
ascites in a patient with ESRD. Nephrogenic ascites is always a diagnosis of exclusion; a rare syndrome
with poor prognosis and lack of well documented evidence based therapies. Available treatment
modalities are frequent dialysis, serial paracentesis with gold standard being renal transplantation.
Other common etiologies of low SAAG ascites should be ruled out in patients with ESRD before
diagnosing nephrogenic ascites, to detect treatable conditions and to avoid unnecessary empirical
therapies. Such an approach should make a clinician more comfortable to discuss this rare syndrome
with patients and their families, emphasize poor prognosis and limited therapeutic options and poor
survival. This is particularly important in under served and undocumented patient population among
whom renal transplantation is not an affordable option.
Right Heart Failure and Hypoxia in Hereditary Hemorrhagic Telangiectasia
Arun Singavi MD, Zainab Ashir MD, Daniel Cieslak BA, Peter-Trung Phan MD.
Introduction: Pulmonary arterial hypertension (PAH) can be either primary or secondary - the
latter associated with many different conditions. These include pulmonary veno-occlusive disease,
connective tissue disease, chronic hemolysis, and other rare diseases such as Hereditary Hemorrhagic
Telangiectasia (HHT).
Case: A 52-year-old obese woman with HHT presented with symptoms of shortness of breath and
severe bilateral leg weeping edema. Initial vital signs were normal and physical exam was limited due to
morbid obesity. Lab evaluation revealed elevated liver enzymes prompting a liver ultrasound, which
demonstrated multiple arteriovenous malformations (AVMs) in all lobes. This was followed by an
echocardiogram with bubble study which showed an ejection fraction of 55-60%, moderately enlarged
right ventricle, severe biatrial enlargement, a small atrial septal defect with a right-to-left shunt, and
moderately elevated pulmonary artery systolic pressures. She underwent right and left heart
catheterization with hepatic vein pressure measurements. This revealed a normal hepatic venous
pressure gradient and markedly elevated right-sided cardiac pressures (pulmonary artery pressure
66/40 mmHg) unresponsive to nitric oxide. Based on these findings, it was determined that the liver
AVMs were not the cause of her right heart failure. The patient was diagnosed with PAH and she was
started on sildenafil and aggressively diuresed.
PAH evaluation included spirometry and polysomnography, which revealed moderate restrictive lung
disease and mild apnea. However, like the liver AVMs, these findings were not considered significant
enough to be the sole cause of her pulmonary hypertension. Work-up for pulmonary embolism was
negative, but chest CT could not exclude a pulmonary AVM. Subsequent genetic testing from the
patient’s sister revealed a mutation in activin receptor-like kinase 1 (ALK-1); a gene associated with both
HHT and PAH.
Discussion: Patients with HHT are at risk for developing PAH from high pulmonary blood flow and from
a high cardiac output state from liver AVMs. All patients with HHT who present with exertional dyspnea
should undergo work-up for liver AVMs as this is the most common cause of PAH in these patients.
Although PAH is an uncommon disease, it is becoming increasingly recognized as a complication of HHT,
especially in patients with mutations in the ALK-1 gene. ALK-1 belongs to the TGF-B family and it has
been suggested that imbalance in the signaling pathway leads to dysregulation of arterial dilatation in
HHT patients. Treatment for HHT-PAH patients is similar to therapy from other causes of PAH, and while
there are no studies evaluating the outcomes of these patients, the overall prognosis is thought to be
An Unusual Case of Low Output Heart Failure as the Initial Presentation of
First Author: Idelle Fraser, MD Michael Jakoby, MD/MA, FACP Trinadh Pilla, MD
Introduction: Hyperthyroidism induces a hyperdynamic circulatory state and may lead to high output
congestive heart failure. Dilated cardiomyopathy and low output heart failure are much less frequently
reported cardiovascular complications of thyrotoxicosis. We present an unusual case of
hyperthyroidism complicated by reversible low output heart failure in a patient without atrial fibrillation
or pre-existing heart disease.
Case Presentation: A 39-year-old woman presented to the Emergency Department with complaints of
progressively worsening postural dyspnea and cough productive of clear sputum. She denied chest pain
or lower extremity edema. Examination was notable for resting tachycardia (115 bpm), hypertension
(170/102 mm Hg), smooth and modest goiter, and soft end expiratory wheezes. EKG revealed poor R
wave progression in the anterior precordial leads but no ischemic changes. Plain films of the chest
demonstrated pulmonary vascular congestion, and brain natriuretic peptide (BNP) was markedly
elevated (1,993 pg/mL). TSH (< 0.01 mIU/L, 0.34-5.60) was suppressed and both free thyroxine (3.4
ng/dL, 0.5-1.3) and total triiodothyronine (243 ng/dL, 87-178) were elevated, providing unequivocal
biochemical confirmation of hyperthyroidism. Left atrial enlargement and significantly reduced left
ventricular ejection fraction (25-30%) were observed on a transthoracic echocardiogram (TTE).
Methimazole and supersaturated potassium iodide (SSKI) were prescribed to treat hyperthyroidism, and
heart failure was managed with a loop diuretic and low dose beta-blocker. Respiratory distress resolved
within 48 hours, and treatment with diuretic, beta-blocker, and methimazole was continued after
hospital discharge. TTE repeated after six months of euthyroid status showed resolution of left atrial
enlargement and recovery of normal ejection fraction (> 55%).
Discussion: Congestive heart failure is an uncommon but well documented initial presentation of
hyperthyroidism, and screening TSH is a Class I American Heart Association recommendation for the
evaluation of new heart failure cases. Atrial fibrillation and male gender are strong risk factors for
hyperthyroidism induced heart failure. Though hyperthyroidism has historically been reported as an
etiology of high output heart failure, there are a growing number of cases such as this one that illustrate
the potential for hyperthyroidism to induce dilated cardiomyopathy and low output heart failure. New
York Heart Association functional class and left ventricular function usually improve within three to six
months of restoring euthyroid status, though up to one-third of patients with low output heart failure
may develop persistent dilated cardiomyopathy.
Two Rare Complications of One Common Chemotherapy Agent
First Author: Rena A Shah, MD1 Julie Kim, MD1 Sai Ravi Pingali, MD2 Linda Blust, MD2 1Division of
General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 2Division of
Hematology/Oncology, Department of Internal Medicine, Medical College o
Introduction: Hepatic veno-occlusive disease (VOD) is a rare complication of high dose chemotherapy
with significant mortality. This condition is most commonly seen in patients undergoing stem cell
transplantation and is the third leading cause of transplant related mortality. Gemcitabine is a common
chemotherapy agent used in the treatment of various cancers, including non-small cell, pancreatic,
metastatic breast, or salvage therapy for lymphoma. This case illustrates two rare complications of
gemcitabine seen in one patient: thrombotic thrombocytic purpura (TTP) and veno-occlusive disease.
Case Description: A 65-year-old female with peripheral T-cell-lymphoma, previously diagnosed by skin
biopsy and hypercellular bone marrow, was admitted with weakness and falls. On evaluation patient
was noted to have progression of disease. Patient was previous treated with CHOP (cyclophosphamide,
hydroxydaunorubicin, oncovin, and prednisone) and ESHAP (etoposide, methylprednisolone, cytarabine,
and carboplatin). Patient was started on gemcitabine and dexamethasone as a third line chemotherapy
regimen. After three days of the first dose of gemcitabine, patient developed elevated liver enzymes and
doubled total bilirubin from 1.6mg/dL to 3.7mg/dL with 2.2mg/dL in direct bilirubin. Patient was noted
to have worsening renal function and thrombocytopenia with schistocytes noted on peripheral smear,
indicative of TTP. Liver biopsy was performed illustrated VOD and recurrent T-cell-lymphoma.
Unfortunately, patient’s medical condition continued to worsen with uptrending bilirubin to 13.9mg/dL.
Patient was subsequently made comfort care and died two days later.
Discussion: VOD is typically seen in patients within first hundred days of receiving allogeneic stem cell
transplantation and associated with chemotherapeutic agents like busulfan and cyclophosphamide. It is
believed to be related to endothelial injury in liver venules. This disease is characterized by liver
dysfunction, right upper quadrant pain, weight gain, and ascites, and often associated with renal failure.
VOD is diagnosed by using non-invasive tests like right upper quadrant ultrasound with Doppler studies,
but liver biopsy is the gold standard. Gemcitabine is a nucleoside analog and replaced cytadine in DNA
replication, arresting tumor growth, thus leading to apoptosis and targets ribonucleotide reductase,
inhibiting DNA replication and repair. Common side effects include myelosuppression, interstitial
pneumonitis, hepatic failure, hemolytic uremic syndrome, and cardiac effects. On literature review, only
a handful of case reports have shown VOD in non transplant setting and even fewer that were believed
to be related to gemcitabine. This case is unique in that it illustrates a chronological relation between
gemcitabine and biopsy-proven VOD and TTP, which is seen in 0.25% of patients, in a non-bone marrow
transplant patient. It is important for clinicians to recognize VOD in the context of gemcitabine
exposure, in patients with symptoms suggestive of VOD even if they are not stem cell transplant
recipients so they may be managed aggressively given severe mortality associated with the disease.
Concurrent primary lung cancer of different histological types
First Author: Indrajeet Mahata, MD ,MBBS second author :Puneet Agarwal, MD third author :Dr. Danish
Thameem MD
The curious case of unwanted pair of lung cancer !
Introduction: Lung cancer is the leading cause of cancer-related death among men and women and
second leading cause of cancer in the United States. Primary lung cancer is commonly accompanied by
malignancies of the upper respiratory tract, breast and GI tract. However, the concurrent primary
malignancies with different histo-pathological presentations in the same organ are often overlooked and
missed, if the patient is not thoroughly evaluated.
Case Presentation: Our patient is 67-yr-old white male with past medical history of 40 pack-year smoke
history (smoke-free from last 9 months), and severe emphysema (recent FEV1-0.79) who presents to his
pulmonologist for routine follow-up visit. He complains of some chronic cough with minimal clear
mucus, unchanged from his baseline. He denies any new shortness of breath, hemoptysis, and weight
loss. A routine chest x-ray obtained prior to visit shows increased density involving the left upper lobe
which is new compared to the previous chest x-ray, 2 years back. To follow up further, a chest CT is done
which shows 4.9 x 4.2 cm left upper lobe mass with spiculated margins and non-calcified mediastinal
and right hilar lymphadenopathy. The patient undergoes bronchoscopy and trans-bronchial biopsy of
left and right upper lobe. The pathology is found to be consistent with Squamous-cell carcinoma in-situ
from the right upper lobe but non-diagnostic in the left upper lobe. Given the strong clinical history and
radiological findings suspicious for malignancy in the left upper lung, patient undergoes second
bronchoscopy with trans-bronchial biopsy. This time, the results of pathology are consistent with smallcell cancer in the left upper lobe. A PET scan done for further evaluation of the lung cancer shows
additional hyper-metabolic lymph node in mediastinal, hilar, and supraclavicular region. He is referred
to oncology for further treatment and undergoes aggressive chemotherapy eventually.
Discussion: Establishing the diagnosis of multiple primary bronchogenic carcinomas requires
demonstration of histologic, anatomic or temporal separation of the tumors. There are no specific
clinical or radiological features that can differentiate multiple primary lung cancers and intra-pulmonary
metastases. The key to early diagnosis of multiple primary lung cancers lies in high clinical suspicion,
detailed examination of the respiratory tract and regular follow-up of those who are at high risk.
Multiple methods of management, mainly resection combined with chemotherapy or radiotherapy
should be adopted according to the staging, histologic types and biologic characters of the tumors.
Prevention, rather than screening, is the most effective strategy for reducing the burden of lung cancer.
To emphasize the least, the promotion of smoking cessation is essential, as cigarette smoking is felt to
be causal in almost 90 percent of all lung cancer.
Myocardial Infarction Is Not the Only Cause of Chest Pain.
First Author: Adnan Khan, MD Irfan waheed, MD Ahmed Ghadai, MD Rashid Nadeem, MD Hasnain
Bawaadam, MD Jennifer Ota, MD
Introduction: Pulmonary AV malformations are caused by abnormal communication between
pulmonary Artery and pulmonary vein and are rare cause of pulmonary symptoms.70 percent cases of
pulmonary AV malformations are associated with hereditary hemorrhagic telangiectasia.
Case Presentation: 51 years old smoker with past medical history of hypertension and Hyperlipidemia
was brought to the Emergency department for the complain of chest pain for 2 days, the pain was
localized to the right side of chest, 9/10, sharp stabbing in character, does not radiate, does not increase
or decrease with body movement or deep inspiration or expiration, patient denied any chest trauma,
cough , fever or Shortness of breath, No recent history of travel, No diaphoresis ,nausea and vomiting.
Patient had similar episode of pain three days back for few hours which resolved spontaneously and he
did not seek any medical attention. On examination Patient was alert and awake, holding his chest,
vitally stable , there was no costochondral tenderness and Auscultation of chest was normal, there was
no leg swelling or tenderness. Base line labs were within Normal limits, Workup for MI was negative,
and EKG showed Normal sinus Rhythm, D-dimer was negative. CXR was ordered which showed
suspicious right hilar mass. After which CT Thorax was done which showed Large arteriovenous
malformation in the right hilum with a dilated pulmonary artery draining into the left atrium through a
dilated pulmonary vein, Patient was given pain medication for his chest pain and Pulmonary department
and vascular surgeon were consulted and because of high risk of rupture of symptomatic AV
malformation patient was transferred to the other hospital for further workup and possible
Embolization or Surgery.
Discussion: Pulmonary Arteriovenous malformations are Rare and usually present in children and young
adults.The most common symptoms for presentation are Dyspnea (50 %), Hemoptysis (20 %), Stroke (20
%) and Brain Abscess (5%).Most of the pulmonary AV Malformations are Asymptomatic and diagnosed
incidentally during diagnostic workup for other medical conditions. Pulmonary AVM are two times more
common in women than men. Our patient was Unique in that way that he was Male, presented at the
Age of 51 years with Chest pain without other symptoms of Pulmonary AV malformation and without
any association with hereditary hemorrhagic telangiectasia, which is unusual and this emphasizes that
we should also keep in our mind the rare causes of chest pain during workup for chest pain.
Million dollar workup! Not always a waste..
First Author: Maryam Gul, MBBS Haris Bilal, MD; Charles Davies, MD; Michael Tsipursky, MD
Introduction: Acute vision loss is a frightening & debilitating experience which may be caused by some
local reversible etiology or may as well bring with it a whole myriad of signs and symptoms revealing a
rare and underdiagnosed condition.
Case Presentation: We present a case of a 43 year old Caucasian lady who initially suffered from
multiple episodes of headaches. These were followed by symptoms of unilateral hearing loss. Initial ear,
nose and throat evaluation was unrevealing. However with continued symptoms of hearing loss,
audiometric assessments were done showing mild to moderate sensorineural hearing loss (SNHL) in the
lower frequencies. Her course was later complicated by a transient psychotic episode. Two weeks later,
she woke up with difficulty seeing in the lower half of right visual field. Ophthalmological examination
showed a branch retinal artery occlusion and retinal vasculitis. A broad autoimmune workup including
antinuclear antibodies, rheumatoid factor, human leukocyte antigen B27, granulocyte antibodies, lyme
serology, flourescent treponemal antibody-absorption, C-reactive protein, homocysteine,
antiphospholipid antibodies, paraneoplastic panel was found to be negative. Magnetic resonance
imaging (MRI) revealed foci of restricted diffusion in the corpus callosum, punctate acute infarcts in the
right anterior corona radiata and left caudate head. A four-vessel angiogram was negative. Multiple
sclerosis (MS) was ruled out after an equivocal cerebrospinal fluid analysis, negative MS panel, and
atypical MRI findings. Taking into account her clinical presentation supported by neuroimaging and
audiometric evaluation, an aggressive, immunosuppressive therapeutic approach was adopted targeting
a diagnosis of Susac syndrome (one of the rare primary central nervous system angiitis). Recently
plasmaphresis has been started on her, showing improvement in vision and headaches for the first time
in many weeks.
Discussion: Susac syndrome is a rare disease characterized by clinical triad of encephalopathy, branch
retinal artery occlusion, and sensorineural hearing loss, with 200 reported cases so far, mostly in young
women. The diagnosis is based on the clinical presentation, documentation of branch retinal artery
occlusion by fluorescence angiography, and characteristic findings on cerebral MRI in corpus callosum
and periventricular areas. Patients are successfully treated with immunosuppression, however, the best
regimen still needs to be defined. Considering the often severe residual deficits of brain, eye and ear
functions in these mainly young patients, early diagnosis and aggressive treatment are the cornerstones
of management.
Radhakrishna Pillai, MD
Eat more yet feel weak
First Author: Radha Devi Radhakrishna Pillai, MD Second Author: Parakkal Deepak, MD Third Author:
Harvey Friedman, MD
Introduction: Megesterol acetate (Megace) is a synthetic progesterone derivative used in the treatment
of cachexia and anorexia in metastatic cancers or AIDS. It is associated with side effects like
thromboembolism, hypertension, gynecomastia and adrenal insufficiency. Patients with adrenal
insufficiency may present with non-specific symptoms of fatigue, anorexia and decreased libido or
hypotension and cardio vascular instability in times of stress. This case highlights the serious side effect
of adrenal insufficiency caused by Megace.
Case Presentation: A 65 year old man with past medical history of coronary artery disease,
hypertension, abdominal aortic aneurysm, and failed renal transplant on hemodialysis, was admitted to
the hospital with complaints of altered mental status. He had been placed on Megace 800 mg per day to
treat decreased appetite and weight loss of 60 lb over the last 2 months. Physical exam revealed no
mucosal or flexural hyper pigmentation with a normal blood pressure and neurological exam. Basic labs,
thyroid function test and CT scan of the head were normal. An 8 am serum cortisol level was less than
6.2 microgram per deciliter(mcg/dl) and a low dose cosyntropin test was performed revealing cortisol
level of < 1mcg/dl and ACTH level of 11 pg/ml indicating secondary adrenal insufficiency. A CT of the
abdomen (done to rule out malignancy) revealed enlargement of his abdominal aortic aneurysm.
Megace was discontinued and he was started on stress dose of steroids with hydrocortisone at 100mg
intravenously every 8 hours, prior to undergoing endovascular repair of his aneurysm. He was
discharged on a gradual taper of oral hydrocortisone with instructions not to resume megace on
Discussion: Megace is postulated to lead to a suppression of the hypothalamic pituitary axis by its
glucocorticoid like action especially when used in doses more than 300mg per day. Patients may present
with symptoms of acute adrenal insufficiency in times of stress or non specific symptoms of chronic
adrenal insufficiency like fatigue. It is essential for physicians to be aware of this potentially life
threatening side effect prior to prescribing this medication. Hence, patients receiving chronic high dose
Megace therapy may need stress doses of glucocorticoids in times of stress. It has also been suggested
that patients should be prescribed Megace as an appetite stimulant only for shorter periods and should
be tapered off to avoid precipitating an adrenal crisis.
Conclusion: It is important to recognize the early symptoms and signs of adrenal insufficiency secondary
to this under recognized etiology, in order to prevent morbidity and mortality.
Krishnan, MD
Lung Mass And Pleural Effusion – Planning For A Biopsy? Test The Urine
Before That!
First Author: Sathish Kumar Krishnan, MD Second Author: Malav Parikh, MD Third author: Dima
Dandachi, MD
Case Presentation: A 30 years old female presented with non-productive cough, shortness of breath on
exertion, left-sided pleuritic chest pain, and an episode of hemoptysis progressively worsening for 14
days. About 10 days prior to admission, she presented to the ER with fever, non-productive cough and
left-sided pleuritic chest pain. Her chest X-ray then, showed a rounded opacity in the left parahilar
region and a small left pleural effusion. A CT of chest then, showed a 5.4 x 3.3 cm pleural-based
consolidation or mass along the anterior aspect of the left upper lobe at the level of the left hilum and
scattered smaller nodular opacities in the left upper lobe. She was discharged with levofloxacin, but she
did not improve. Her past medical history included asthma, a positive PPD and a normal CXR, 5 months
back, and BCG vaccination at birth. She emigrated from Guyana 15 years back. She is a nurse. She had
never smoked. She had no family history of cancer, connective tissue disease or immunologic disease.
Clinical Course: Her vitals were stable. Her physical exam revealed decreased breath sounds in the left
middle and lower lung fields. Her CXR showed a large left side pleural effusion. Thoracentesis yielded
1500 ml of clear yellow fluid. Pleural fluid analysis: LDH-127IU/L, Glucose-103mg/dL, protein-5.3g/dL
and WBC-100. Quantiferon TB gold, urine legionella and streptococcus antigens were negative. Blood
culture, pleural fluid gram stain, AFB stain, KOH preparation and culture were negative. A CT-guided
biopsy of the lung mass was contemplated. Urine blastomyces antigen was tested before obtaining the
biopsy and it was positive. The patient was treated with itraconazole. She improved clinically and a
follow-up CXR in 6 weeks showed complete resolution of the mass.
Discussion: Blastomycosis is a systemic pyogranulomatous infection that arises after inhalation of the
conidia of the fungus, Blastomyces dermatitidis. Although it can involve any organ, lungs are the most
common site of infection. Pulmonary blastomycosis can cause alveolar infiltrates, fibronodular opacities
and mass lesions. Although small pleural effusions are frequent, large pleural effusions are uncommon.
Our patient is unique that she had a large pleural effusion. Due to the variability of the presentation and
its rarity, it is important to maintain a high index of suspicion in patients with non-resolving pneumonia.
Definitive diagnosis requires growth of the organism from a clinical specimen, but urine antigen
detection has a sensitivity of 90% and a specificity of 80% and has proven useful. Urine antigen levels
can be used to monitor the response to treatment. Urine antigen detection should be done before
biopsy in all suspected cases, as it can preclude the need for biopsy and therefore the risk of
complication, discomfort and expense associated with an invasive investigation.
Rash with Pulmonic Valve Vegetation: A Rare Case of Disseminated
Gonococcal Endocarditis
First Author: Kalyani Chandra, MBBS Faculty Author: Andy Arwari, MD
Introduction: Gonorrhea is the second most commonly reported sexually transmitted disease (STD) in
the United States, with approximately 300,000 cases reported annually. Gonococcemia occurs in 0.5-3%
of patients infected with Neisseria gonorrhea. Endocarditis is a rare complication, which was reported in
1-2% of patients with gonococcemia. We report a rare case of gonococcemia with isolated pulmonic
valve vegetation here.
Case Presentation: A 23-year-old Asian female healthcare technician presented to the emergency
department with left wrist pain, painful rash, fever, and occasional shortness of breath. She denied
dysuria, vaginal discharge, sore throat, insect or animal bites, inappropriate exposure to body fluids, or
history of STDs. She did have new tattoos recently. She is monogamous, uses condoms inconsistently,
and has intrauterine device (IUD). Physical exam revealed multiple 4-5 mm tender maculopapular
lesions and pustules with eschar in her hands, multiple tattoos, and mild swelling with limited range of
motion in the left wrist. No heart murmurs were appreciated. Pelvic examination revealed white, thin
discharge with no cervical motion tenderness. Laboratory data were remarkable for leukocytosis of
16,340 (4000-11,000/microliter) with 85% neutrophils, ESR of 49 (0-25 mm/hr), and CRP of 61.3
(<10mg/L). The patient was treated empirically with intravenous vancomycin, gentamycin and
levofloxacin. The cervical swab was positive for gonorrhea. Testing for chlamydia, pregnancy, HIV,
syphilis, and autoimmune panel were all negative. Antibiotics were changed to intravenous ceftriaxone
and oral doxycycline. Blood cultures were positive for N. gonorrhea. IUD was removed.
Transesophageal echocardiogram revealed a 1x0.7 mm mobile echodensity on pulmonic valve which
was concerning for vegetation. Cardiothoracic surgery recommended deferring surgery until there is
pulmonic valve dysfunction. Her symptoms improved with antibiotic treatment. She was subsequently
discharged home on continuation of intravenous ceftriaxone for 4 weeks.
Discussion: The incidence of gonococcal endocarditis has decreased in the post-antibiotic era; however,
the mortality rate continues to be high around 20%. Literature review shows high predilection to aortic
valve (50%), followed by mitral valve (30%). Isolated pulmonic valve gonococcal endocarditis is very rare
with only 3 reported cases in the post-antibiotic era. Patients with gonococcal endocarditis generally
present with non-specific symptoms. This is an aggressive infection and can destroy the valve in hours to
days, even with antibiotic treatment. Echocardiogram is an indispensable tool for diagnosis, but late
presentations and negative blood cultures can make the diagnosis challenging. Valve replacement is
warranted in cases with severe pulmonary valve dysfunction. Nonetheless, unlike left-sided
endocarditis, right sided endocarditis responds well to antibiotic therapy. High index of suspicion, good
history, and early antibiotic therapy with close monitoring are essential in diagnosis and management of
gonococcal endocarditis.
Pyogenic liver abscesses: manifestations and management of an evolving
First Author: Atena Lodhi, MD Diana Purushotham, MD David David, MD Michael Kron, MD Sumanta
Chaudhuri, MD
Introduction: Pyogenic liver abscess is a severe disease for which early diagnosis and management is
critical. Hyperviscous variants of Klebsiella pneumonia have been reported as originating in China,
Taiwan, and Southeast Asia. The K1 serotype of Klebsiella pneumonia produces a large amount of
hyperviscous inflammation, which is often not amenable to percutaneous drainage and inhibits
penetration of appropriate antibiotics.
Case Description: A 60-year-old male with no significant past medical history was admitted with a 5 day
history of right upper quadrant pain and fevers. The patient recently came to the US from northern
China. He reported a sharp, non-radiating 8 of out 10 right upper quadrant pain associated with mild
nausea. The patient was not on any medications and denied melena, hematochezia, or changes in stool.
He worked as a crane operator, and had no family history of colon cancer but had never had a
colonoscopy. Admission laboratory studies showed no leukocytosis and a normal complete metabolic
panel. Right upper quadrant ultrasound and an abdominal CT revealed multiple hypodense liver lesions
suspicious for hepatic abscesses versus metastatic disease. Blood cultures obtained in the emergency
room showed no growth over 3 weeks. Serologies for hepatitis B and C; stool ova and parasite; E.
Histolytica antibody; Ameobiasis Ag stool test; and cultures for enteric pathogens were all negative. He
was empirically started on piperacillin/tazobactam but continued to have intermittent fevers up to
103ºF so Vancomycin was added. Ultrasound guided percutaneous drainage of the suspected liver
abscess/tumor was attempted multiple times without apparent success since gram stain and cytology of
the scanty material obtained demonstrated no leukocytes. Culture of that material nonetheless grew 1+
pansensitive hypermucoid Klebsiella pneumonia. Despite 14 days of antibiotic treatment MRI revealed
that the abscesses were increasing in size. Therefore laparoscopic drainage of the multiloculated
abscess cavities was performed. Intraoperative cultures of the copious mucoid material grew 3+
pansensitive K. pneumonia. Postoperatively the patient did very well, and completed a four-week course
of IV ertapenem with complete resolution of his liver abscesses.
Discussion: The hyperviscous subtype of Klebsiella pneumonia in Asia emerged in the 1980s and has
since expanded to the US. The capsular K1 serotype of K. pneumonia, has virulence genes magA, rmpA,
and aerobactin, conferring resistance to neutrophil phagocytosis and serum complement killing.
Primary liver abscesses can be further complicated with metastatic infection developing in 10-12% of
patients, with metastasis primarily involving the ocular or central nervous system. The surgical literature
recommends percutaneous drainage and antibiotics in small (<3cm) or unilocular abscesses. However, in
the case of liver abscesses with mucoid K. pneumonia medical management often fails. Identification of
hypermucoid K. pneumonia abscess should be a strong indicator for early surgical intervention.
Dramatic Intracerebral Hemorrhagic Presentations of Reversible Cerebral
Vasoconstriction Syndrome: three cases and literature review
Bonnie Wang MD, Joel Stary MD, Huan (John) Wang MD
Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is arecently recognized banner
term for a number of disorders previouslycharacterized by the clinical manifestation of severe, suddenonset (often“thunderclap”) headaches along with the angiographic feature of reversible,segmental,
multifocal vasoconstriction of cerebral arteries. Although RCVSgenerally resolves without significant
sequelae, the increasingly recognizedhemorrhagic presentations have lent a sinister bent to the
syndrome’s potentialcourse and indicated the need for more prompt diagnosis and emergent
treatment.However, alarmingly dramatic intracerebral hemorrhage (ICH) remains a rare andpossibly
under-recognized presenting feature of RCVS. We report three suchcases and review the current
Methods: We conducted a retrospective review from 2008 to 2012 and identifiedthree patients with
alarmingly dramatic ICH as the presenting feature of RCVS.Their hospital charts and follow-up records
were reviewed and summarized.
Results: This retrospective study identified three healthy females (42, 54, and33 years-old, respectively),
who presented with severe headache, neurologicaldeficits, and alarmingly dramatic ICH. All three were
subsequently found tohave RCVS. Patient 1 presented in a comatose state and had a 9 x 4 x 6.6 cmleft
deep intraparenchymal hemorrhage with one-cm midline shift. She underwentemergent surgical
intervention. Patient 2 had a 3.3 x 1.5 cm left superiorfrontal hemorrhage that enlarged to 4 x 2.5 cm
within 12 hours with increasingheadache and neurological deficits. She was successfully managednonoperatively. Patient 3, after an uncomplicated course of pregnancy anddelivery, on postpartum day 7,
presented with a 1.5 cm left superior parietalhemorrhage. Three days later, she developed acute right
hemiplegia and repeatCT demonstrated a new 3.3 x 1.7 cm left frontal hemorrhage. She was
alsosuccessfully managed non-operatively. Initial cerebral angiograms demonstrated severe and diffuse
short-segmentalvasoconstriction in both hemispheres, but without any evidence of
arteriovenousshunting, aneurysms, or venous sinus thrombosis. Three-month follow-upangiograms
demonstrated complete resolution in all 3 patients. Extensivework-up for vasculitic, immunologic and
infectious causes were negative.Cranial MRI evaluations did not demonstrate any unexpected
findings.Additionally, Patients 1 and 2 underwent cerebral spinal fluid analyses andleptomeningeal
biopsies that revealed no remarkable findings. At three-monthfollow-up, all three patients had
significant improvements from presentation,with Modified Ranking Scale of 3 (Patient 1), 0 (Patient 2),
and 1 (Patient3).
Conclusions: Currently, many diverse conditions are grouped within the categoryof RCVS; yet, they may
or may not share the same underlying pathophysiology.Although there is an increased awareness of
hemorrhagic presentations of RCVS,alarmingly dramatic ICH remains a rare and possibly underrecognized presentingfeature of RCVS. Familiarity of this clinical entity for prompt diagnosis
andmanagement is essential for cerebrovascular neurosurgeons, vascularneurologists, neurocritical-care
physicians, and neuro-hospitalists.
Multiple Myeloma Within The Liver
Izabela Postacchini MD , Mark Postacchini MD , Leonard Klein MD
Case Presentation: A sixty nine year old male with medicalhistory of diabetes mellitus presented with
progressively worseninglocalized right lower back pain that was constant without radiation. AfterX-ray
and a questionably negative MRI of the spine, a second MRI scan performedfour months later revealed a
nine cm mass in the right iliac wing, later confirmedwith a skeletal survey, and a three cm soft tissue
pelvic mass. Subsequent bonemarrow biopsy, aspiration, and flow cytometry was negative and 24 hour
urinecollection revealed only trace monoclonal proteins. CT guided biopsy of theiliac mass was
consistent with a plasmocytoma. Radiation Oncology was consultedand prior to initiation of external
radiation a CT of the abdomen and pelvis was orderedwhich revealed multiple lesions throughout the
liver. Kappa free light chains were found in theblood. There were no clinical or laboratory signs of liver
disease. CT guidedbiopsy revealed malignant monoclonal plasma cells consistent with multiple
myelomawithin the liver lesions. The patient subsequently underwentPET scanning prior to induction
chemotherapy with Revlimid, Velcase, andDexamethasone resulting in a partial remission. Repeat PET
scanning showed no evidence of the bone and soft tissuelesions. The hepatic metastatic burden also
significantly improved with a decreasein size of some lesions and complete resolution of others.The
patient was later readmitted for consolidationchemotherapy with high dose Melphalan and received an
autologous stem cell transplant without complications.
Plasma cellmyeloma can present as a
solitary plasmacytoma or with multiple lesions. Withinthe bone marrow, myeloma cells replicate and
disseminate systemically causingextra-nodal disease such as osteolytic lesions, renal failure, and
pathologicalfractures. The current staging of multiple myeloma depends on many factors andutilizes
two main staging systems: the International Staging System (ISS) andthe Durie-Salmon Staging System.
Each system utilizes different factors;however, overall staging depends on the following: Patient factors
( e.g.comorbidites, performance status) , laboratory values ( Creatinine, Calcium,Hemoglobin, Platelets),
bone marrow plasma cell immunophenotype (CD 38,56,138),cytogenetics (FISH, karyotyping, Del(17p),
IgH translocations), proliferativerate, and the specific types of monoclonal proteins produced. However,
neitherof the two staging systems incorporate imaging studies as a prognosticatingfactor other than
skeletal survey used only during diagnostics.
Discussion: This case indicates the potential benefitof using imaging studies such as CT, MRI, and PET
scanning to aid in multiple myelomastaging prior to initiating chemotherapy which currently is not
routinelyperformed. It is important to determine any potential extra-nodal disease, especiallywithin the
liver, as it is currently unknown if it correlates with a worseprognosis. We present one of two recent
cases of multiple myeloma with involvement of the liver which is extremelyrare.
More Than Just Your Typical Back Pain-An Unusual Presentation of Diffuse
Large B Cell Lymphoma
First Author: Anita Rajagopal, MD Stephen Knaus, MD Department of Internal Medicine, St. Vincent
Medical Center; Indianapolis, Indiana
Introduction: Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of nonHodgkin lymphoma (NHL) accounting for approximately 25 percent of NHL cases. Typical presentation is
discomfort due to an enlarged lymph node or organ. Here, we present a case of a patient with DLBCL
who presented with intractable back pain and an absence of lymph node enlargement.
Case Presentation: An 81 year-old white male patient was admitted for evaluation of intractable back
pain. The patient had a past medical history notable for atrial fibrillation, anemia and hypertension. He
was otherwise well until 6 months prior to presentation. Upon presentation, the patient had intractable
back pain minimally responsive to pain medication. Imaging was notable for an enlarged left psoas
muscle. Preliminary investigation revealed a psoas mass of unknown etiology. The patient was treated
with IV analgesics. Initial biopsy of the mass only revealed fat necrosis. Increasing pain symptoms in the
patient led to heightened concern and further testing. The case was complicated by the patient’s
sudden development of shortness of breath. Impressive CT images of the chest later revealed ground
glass opacities. Extensive infectious testing was negative. A second biopsy of the psoas mass was
performed, this time using ultrasound guidance. Pathology revealed diffuse large B cell lymphoma, stage
IIIE. After diagnosis, the patient’s metabolic state was optimized and he was started on chemotherapy.
After the first course of chemotherapy, the patient reported a decrease in his back pain. He continues to
receive further chemotherapy treatment. Prognosis, however, is grim given the patient’s age, stage and
disease sites.
Conclusion: Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin
lymphoma. DLBCL typically presents with nodal enlargement in the neck or the abdomen. Extranodal
extramedullary disease occurs in up to 40 percent of cases, most commonly in the gastrointestinal tract,
bone, thyroid, skin, liver, and central nervous system. This case demonstrates that DLBCL can present in
diverse ways. The treatment generally includes chemotherapy and immunotherapy. Prognosis is
dependent upon extent of disease and underlying health of the patient. Thus making the early diagnosis
and early suspicion in atypical presentations crucial.
Fever and rash without localizing symptoms
First Author: Kartik Shatagopam, MD, Sam Fahmy, MD
Case Presentation: A healthy 31-year-old male presents for worsening and persistent headaches, back
pain, muscle aches, fever, and upper extremity weakness. Patient is an avid deer hunter and describes a
non-pruritic, large erythematous, circular, non-target appearing rash on his left thigh after being stung
by a “spider” 6 weeks ago. Associated with generalized malaise and fevers. Rash resolved in 5-6 days.
Subsequently developed large, painful cervical lymphadenopathy and was given Keflex for 1 week during
initial ER visit. Lymphadenopathy resolved but symptoms progressed to constant headaches, diffuse
arthralgias, lower back pain and mild weakness in upper extremities. Development of paresthesias in
legs and arms, neck pain, massive frontal headache, sciatic pain in legs B/L and continued fevers and
malaise led to admission. Recently obtained a cat as a pet within the last 3 months. Upon examination,
had a fever of 100.7 with normal hemodynamics, and profound light sensitivity. Neuro exam revealed
normal ocular findings, 3/5 motor upper extremity strength and normal lower extremity strength. No
obvious meningeal signs were appreciated but had significant neck pain. Initial labs included a WBC of
11.9 and an ESR of 37, CRP of 9.4. EKG showed a new incomplete RBBB. Differential included Lyme
disease, STARI (southern tick associated rash illness), rickettsial diseases or viral syndrome. An LP was
obtained which was bland. Serologies for lyme, CMV, HIV were ordered and patient placed on empiric
ceftriaxone 2g. Infectious disease was contacted and multiple serologies were sent. Patient was
discharged home with ID follow-up on oral doxycycline. All of the serologies returned negative, except
for B. Henselae with positivity for IgG and IgM with a titer of 1:128.
Cat Scratch disease (CSD) is an inflammation of the lymphnodes draining the site of inoculation. Henri
Parinaud is believed to have described the first case in 1889[1]. Bartonella Henselae, a gram-negative
bacillus is the etiologic factor and is transmitted via a bite or a scratch from a cat. Rash precedes the
lymphadenopathy as is described as non-tender, red-brown papules at the site of inoculation and
resolves in about 3-10 days. Typically cervical, submandibular or axillary lymphadenopathy is then seen.
Adenopathy is seen in almost 100% of cases. Systemic symptoms such as fever, malaise, headache,
arthralgias, and an array of neurologic manifestations can occur. Diagnosis is via history and serologic
testing. Immune fluorescence assay sensitivity and specificity is around 100% and 98%[2], respectively.
For IgG and IgM, it is 88-98% and 50-62% respectively. Histopathologic features of lymphnodes include
granuloma formation, stellate abscesses and lymphocytic infiltrates. Culturing the organism is very
different. Treatment is based on clinical progression of disease and is usually azithromycin for local or
doxycycline plus rifampin for suspected systemic disease.
Spach, D, et al. Treatment of Cat Scratch Disease. Uptodate.
Spach, D, et al. Microbiology, epidemiology, clinical manifestations, and diagnosis of cat scratch disease. Uptodate.
Bass JW, Vincent JM, Person DA. The expanding spectrum of Bartonella infections: II. Cat-scratch disease. Pediatr
Infect Dis J. 1997;16(2):163. [1] Jerris RC, Regnery RL (1996). "Will the real agent of cat-scratch disease please stand
up?". Annu. Rev. Microbiol. 50: 707–25.[2] Huang J, Dai L, Lei S, et al. [Application of Warthin-Starry stain,
immunohistochemistry and transmission electron microscopy in diagnosis of cat scratch disease]. Zhonghua Bing Li
Xue Za Zhi. Apr 2010;39(4):225-9.
B12 Deficiency from Carcinoid?
Sean Teagarden, DO, MS Department of Internal Medicine, Indiana University School of Medicine,
Indianapolis, IN
Viplove Senadhi, DO Division of Gastroenterology and Hepatology, Indiana University School of
Medicine, Indianapolis, IN
A 59-year-old white male with past medical history of diabetesmellitus, hypertension and
hyperlipidemia presented to the Endoscopy unit forevaluation of new onset anemia in the absence of
overt bleeding. He alsoreports mild heartburn for which he does not use a PPI. Review of systems
wasotherwise negative. Past surgical history was significant for cholecystectomy.Non-contributory
family history.
Lab data showed Hemoglobin 12.5, MCV 102, RDW19.4, Iron 134, and Ferritin 7.3. EGD showed a small
papule in the gastriccardia, multiple small papules in the gastric antrum and pre-pyloric region.
Nobleeding or stigmata of recent bleeding. The papules were biopsied. Pathologyof the gastric cardia
papule revealed carcinoid tumor. It was 0.4 cm ingreatest dimension. No helicobacter pylori-like
organisms identified.Immunohistochemical staining was consistent with carcinoid tumor. The
otherbiopsies showed atrophic gastritis. CT with IV contrast of the chest, abdomenand pelvis showed
mild thickening of the gastric antrum. Further work uprevealed gastrin level off PPI 1651 pg/ml, B12
level 77 pg/ ml, Ca 8.4 and PTH50.9, anti-parietal cell antibodies negative and anti-intrinsic factor
antibodiespositive. Endoscopic ultrasound (EUS) re-demonstrated the papule in the gastriccardia and
showed wall thickening in the body of the stomach. EUS biopsy of thepapule confirmed carcinoid tumor.
Treatment endoscopy was successfullycompleted with snare mucosal resection and fulguration. Gastric
carcinoids are relatively rare tumors of thegastrointestinal tract. The prevalence of gastrointestinal
carcinoid tumors inthe US is 35/100,000. The incidence of gastric carcinoids has increased 10 foldover
the last 35 years. There are three types of gastric carcinoid tumors. Type1 is the most common,
occurring in 70-80% of cases. It is associated withchronic atrophic gastritis and B12 deficiency. Usually
affects women aged 50-70years old. Presentation is normally asymptomatic or in the setting of
macrocyticanemia. Metastasis is rare, occurring in less than 2% of cases. Treatmentinvolves observation,
endoscopic resection or antrectomy. Type 2 makes up lessthan 5% of patients and is associated with
gastrinomas (zollinger-ellison).
Thus the presence of significant peptic ulcer disease helps differentiate itfrom Type 1 tumors.
Metastasis is rare and treatment involves endoscopicresection, antrectomy, octreotide or gastrectomy.
Type 3 carcinoids occur in15-20% of cases. They often manifest with carcinoid syndrome and
havemetastasized 65% of the time on presentation. Treatment is surgical or withchemotherapy.Our
patient had a Type 1 gastric carcinoid tumor. As isoften the case, it was incidentally found during the
evaluation of macrocytic anemia.He also had the characteristic atrophic gastritis and B12 deficiency. It
isimportant for internists to consider gastric carcinoid in the setting ofunexplained B12 deficiency and
macrocytic anemia.
First Author: Nabil M. Mansour, MD Second Author: Maha A. Assi, MD, MPH
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon but potentially lifethreatening condition. HLH may be primary (genetic), but is usually secondary in adults and may be
triggered by various etiologies, including viral, bacterial, fungal, and parasitic infections. HLH is
diagnosed if five of the following criteria are met: fever, splenomegaly, cytopenia in two or more cell
lines, hypertriglyceridemia or hypofibrinogenemia, low/absent NK-cell activity, ferritin > 500 ng/mL,
soluble interleukin-2 receptor > 2400 U/mL, and hemophagocytosis in bone marrow, spleen, or lymph
nodes without evidence of malignancy. HLH secondary to Anaplasma infection has not been previously
reported in the literature. We present a patient who fulfilled the diagnostic criteria for HLH, but whose
illness was caused by infection with Anaplasma phagocytophilium.
Case Presentation: A previously healthy 20-year-old male was hospitalized with a two-month history of
fever, vomiting, diarrhea, and malaise. He had thrombocytopenia, leukopenia, and elevated
transaminases, ferritin, and triglycerides. A CT scan revealed splenomegaly. A bone marrow biopsy
revealed hemophagocytosis with no evidence of malignancy. HLH was diagnosed as he met six of the
necessary criteria. A comprehensive infectious workup was negative except for a positive IgG titer (1:64)
for Anaplasma phagocytophilium. The patient was started on doxycycline and showed rapid
improvement. At one-month follow-up, the Anaplasma titer increased to 1:128, further suggesting the
diagnosis. The patient reported resolution of symptoms and laboratory studies normalized.
Discussion: Many patients with HLH have a rapidly deteriorating clinical course with multi-system organ
failure and require chemotherapy. Our patient had a relatively stable clinical course without significant
deterioration. Consequently, treatment with chemotherapy was withheld while the patient’s symptoms
resolved by treating his Anaplasma infection with doxycycline. This case illustrates the importance of
considering all possible underlying causes, including infections, in a patient who meets the diagnostic
criteria for HLH. Identification and treatment of the underlying cause may resolve the disease process
and spare patients the adverse effects of chemotherapy.
First Author: Sapna A Shah-Haque, MD
Introduction: Over 90 percent of cases of primary adrenal insufficiency are secondary to autoimmune
adrenalitis. However, the adrenal glands are particularly susceptible to metastatic disease and
opportunistic infection, sometimes making determination of the etiology of adrenal insufficiency a
challenge to the clinician.
Case Presentation: We report a 58-year-old immunocompetent male who presented to an outside
emergency department with febrile illness, hypotension, hyponatremia, hyperkalemia, and acute renal
failure immediately following coronary artery angiography. His hypotension was refractory to empiric
antibiotic and pressor treatment for septic shock. Computerized tomography (CT) with and without
contrast of the chest, abdomen, and pelvis with contrast—performed for evaluation of his febrile
illness—revealed bilateral, heterogeneously enhancing adrenal masses measuring 3.8 cm x 3.1 cm on
the right and 4.2 cm x 3.6 cm on the left. Cytologic findings from a CT-guided fine needle aspiration were
compatible with Histoplasma capsulatum adrenalitis. Work up for an immunocompromised state,
including but not limited to testing for Human Immunodeficiency Virus and hepatitis, was negative.
Following failure of the serum cortisol level to rise with high-dose Cosyntropin stimulation, steroid
replacement was initiated with hydrocortisone and fludrocortisone, and antifungal therapy was
initiated. The patient’s hypotension and electrolyte abnormalities resolved immediately, and he was
discharged home in good condition.
Discussion: Histoplasma capsulatum is endemic to the United States; however, disseminated
histoplasmosis is rare in immunocompetent individuals. The clinician should consider the diagnosis of
primary adrenal insufficiency in clinical presentations of hypotension. Furthermore, clinicians should
consider infectious causes of adrenalitis in cases of primary adrenal insufficiency.v
First Author: Maya Estephan, MD
Introduction: Rheumatoid arthritis (RA) is a chronic systemic inflammatory illness. Lung involvement
from RA is common and pulmonary nodules have been described in 4 to 20% of patients. Symptomatic
pleural manifestations occur in 3 to 5% of cases. Rarely, pulmonary nodules become necrotic and lead to
pneumothorax. Pulmonary rheumatoid nodules can present a challenge for diagnosis.
Case Presentation: In 2006, a 70-year-old male was evaluated for a right lower lobe 2 cm lung nodule.
He was an ex-smoker with a history of RA since the 1980s treated with multiple lines of therapy,
including methotrexate. A Computed Tomography (CT) guided biopsy of the nodule revealed chronic
inflammation. On follow-up in early 2009, the nodule was larger, 2.6 cm in size. A repeat CT guided
biopsy revealed pneumocyte hyperplasia, inflammation, and intra-alveolar bleed. A repeat biopsy 6
months later showed again similar findings, changes consistent with connective tissue disease. Stains
were negative for fungal and tuberculosis. In 2010, due to continuous growth in nodule size, a Positron
Emitting Tomography (PET) scan was done and showed increased uptake of the right lower lobe nodule
in the neoplastic range. Subsequently, a right lower lobectomy was performed revealing a grade 2
adenocarcinoma of lung origin.
Discussion: Patients with RA have a higher incidence of lymphoma and lung cancer. The pathogenesis
seems to be triggered by the underlying auto immune process and possibly the immunosuppressive
therapies. Also, rheumatoid lung nodules are common in patients with RA on methotrexate or
leflunomide. Malignancies and infections, like tuberculosis, should be part of the differential diagnosis
when managing a rheumatoid nodule with significant uptake on PET imaging.
Autoimmunity Loves Company
First Author: Bharat Kumar, MD
Autoimmunity Loves Company
Introduction: Autoimmune polyendocrine syndrome type 1 (APS-1) is a rare disorder characterized by
the loss of immunological tolerance to several endocrine tissues. Patients present variably with
mucocutaneous candidiasis, hypoparathyroidism, and hypoaldosteronism, although other autoimmune
phenomena have also been associated. We present the case of a patient with APS-1 who developed
antibodies against glutamic acid decarboxylase, resulting in stiff-person syndrome.
Case Presentation: A 35-year old female patient with APS-1 diagnosed in infancy and manifested by
hypoaldosteronism, hypoparathyroidism, mucocutaneous candidiasis and vitiligo presents with rigidity,
stiffness and painful spasms in the lower back and thighs. It started gradually over the past three
months and was presumed to be due to chronically low levels of potassium and calcium. Despite
aggressive repletion, the symptoms worsened and spread to both legs. This stiffness was exacerbated
by emotional stress and improved by diazepam. Vital signs were within normal limits (BP: 94/67; HR: 91;
RR: 14; Temp: 96.7; SatO2: 98% on room air). Physical examination revealed a thin female with
extensive patches of depigmentation over the hands and legs. Her posture was lordotic and muscle
tone of both hip flexors and extensors were increased, though pain limited the extent of examination.
Bicipital and patellar reflexes were 3+ bilaterally. The rest of the neurological examination was
unremarkable. Laboratory testing revealed hypokalemia (K+: 3.3) and hypocalcemia (Ca++: 8.3) in line
with previous values in the past year. Given her insidious and worsening course, stiff-person syndrome
was considered, and so glutamic acid decarboxylase antibody titers were ordered, which were elevated
(40.7 IU/dL), consistent with the diagnosis. Intravenous immunoglobulin therapy was started, resulting
in improvements in stiffness and spasms after twelve months of therapy.
Discussion: Stiff-person syndrome (SPS) is a rare autoimmune disorder characterized by muscle rigidity
and hypertonicity. 90% of cases are believed to be mediated by antibodies to glutamic acid
decarboxylase (GAD65), leading to decreased synthesis of gamma-aminobutyric acid (GABA), a
neurotransmitter that ordinarily inhibits muscle contraction. Patients present acutely or subacutely
with muscle spasms, stiffness and rigidity, most commonly in the back and lower extremities. These
symptoms are characteristically worsened by emotional stress and fatigue and are relieved by
benzodiazepine use. Diagnosis is supported by high levels of GAD65 antibodies, though this finding is
nonspecific. Intravenous immune globulin therapy, immunosuppression, and symptomatic treatment
with benzodiazepines are mainstays of therapy. SPS has been associated with other endocrinopathies,
most notably type 1 diabetes mellitus, hypothyroidism, and autoimmune polyendocrine syndrome type
2. SPS may also be paraneoplastic to various solid and hematologic malignancies.
This case reminds us that autoimmune syndromes are actually the outward manifestations of deeper
immunological derangements, and so, whenever one syndrome is present, another may not be too far
Sumatriptan Induced Hypertensive Episodes Presenting As
First Author: Nirmanmoh Bhatia, MD Second Author: Shruti Chaturvedi, MD
Introduction: Severe paroxysmal hypertension often engenders a search for a catecholamine-secreting
pheochromocytoma. However, more than 98% of patients with this presentation do not have this
tumor. We describe a case of sumatriptan induced paroxysmal hypertension presenting as
Case Description: A 49 year old Caucasian female with a history of hypertension and migraine
headaches presented to the emergency department with acute onset of severe fronto-temporal
headache, dizziness and blurry vision. She reported having 8 such episodes in six months. Physical
examination revealed a heart rate of 110 beats/min and blood pressure of 250/110 mm Hg. Her
symptoms resolved after treatment with nitroprusside and labetalol. She had been diagnosed with
hypertension a year ago and was being treated with hydrochlorothiazide and valsartan. Her migraine
headaches were being treated with sumatriptan but had become more severe and frequent over the
past six months. She was compliant with her medications and denied illicit drug use or recent
psychosocial stressors.
During her admission, two episodes of severe symptomatic hypertension were witnessed, both heralded
by a headache and associated with dizziness and visual blurring and responded to labetalol. In between
episodes, she was normotensive on hydrochlothiazide and valsartan. She underwent evaluation for
catecholamine secreting tumors (24 hour urinary catecholamines and metanephrines), hypercortisolism
(serum cortisol, 24 hour urinary cortisol) and hyperthyroidism (TSH) and all results were within the
normal range. During the course of the admission it became evident that these hypertensive urgencies
occurred after she took sumatriptan for her headache which suggested that her hypertensive crises
were precipitated by sumatriptan. Sumatriptan was withheld and no further hypertensive
episodes occurred.
She was started on topiramate for migraine prophylaxis with NSAIDS instead of sumatriptan for abortive
therapy. She was continued on hydrochlorothiazide and valsartan for hypertension and demonstrated
good blood pressure control for the next one year of followup.
Discussion: The triptan class of anti-migraine medications can cause vasoconstriction through their
agonist effect on the 5-HT1B serotonin receptors present in arteries and veins. We hypothesize that a
similar mechanism operates to cause hypertensive crises. Recognition of this association is critical in
preventing further episodes and potentially avoiding complications such as strokes, acute coronary
syndromes and flash pulmonary edema.
Franco, MD
Carcinoid syndrome, a heart disease
First Author: Diego Alcivar Franco, MD
Case Presentation: 67 year old white female who presents with 8 weeks of progressive fatigue,
dyspnea on exertion, lower extremity edema and diarrhea with watery stools ranging from 10 to 12 per
day. She has gained 10 pounds in 2 weeks and does not experience flushing or wheezing. In physical
examination presents a pansystolic murmur heard in left lower sternal border increased with
inspiration, JVP 8 cm with a prominent V wave. Abdominal distention with hepatomegaly with liver edge
4 cm below the right costal margin. Presents lower extremity edema 2+. CT abdomen showed multiple
hepatic lesions and large splenic mass confirmed with Octreoscan, Echocardiogram showed severe TR
with tricuspid valve leaflets thick and retracted, with lack of coaptation, Severe RV dilatation, mild to
moderate RVH, moderate to severe decrease in RVSF. Small pericardial effusion. Patient 5-HIAA was 244
mg/g and was started on Octeotride 150mcg q8h for the first two weeks then changed to Octeotride ER
30mg IM every 4 weeks, with significant improvement in diarrhea to 2 bowel movements daily, also was
started on diuretic regimen improving fatigue and dyspnea. Since the start of treatment the patient has
lost 94 pounds in 5 months, returned to her working activity, has received Y-90 radioembolization
treatment and her tricuspid valve replacement is programmed by Cardiothoracic surgery.
Discussion: CHD may be initial presentation in up to 20 % of patients with carcinoid syndrome and will
eventually occurs in over 50% with this disease. It’s characterized by plaque like deposits of fibrous
tissue that mostly affects the right heart valves, most commonly tricuspid regurgitation (Moderate to
Severe in 90%), because of inactivation of humoral substances by the lung protect the left heart, but
when happens is associated with an atrial right-to-left shunt or a primary bronchial carcinoid. The
pulmonary valve can be regurgitant (81%) or stenotic (53%). Evidence suggests a role for serotonin in
the severity of cardiac involvement, urinary 5-HIAA values averaged 356 mg/day in those with heart
disease compared to 99 mg/day in those without cardiac involvement. Clinically can be subtle early in
the course, then range from fatigue and dyspnea on exertion to edema, ascites, and cardiac cachexia.
Physical findings include an elevated jvp, palpable RV impulse, and murmurs of tricuspid and pulmonary
valve regurgitation. Baseline echocardiogram is recommended in all patients with carcinoid syndrome;
with follow-up when clinical features of right heart failure. CHD with advanced symptoms (NYHA III or
IV) have a poor prognosis with a median survival of 11 months. Elevated CgA and NT-pro BNP are
associated with overall mortality (16% survival in 5years). Tricuspid and pulmonary valve replacement is
the only effective treatment, indications for surgery: impaired exercise capacity, progressive fatigue and
progressive decline in ventricular function in the presence of controlled metastatic carcinoid disease.
Anesthesia can precipitate carcinoid crisis thus octreotide is required peri and postoperative. Survival
over time with surgery has improved from 1.5 to 4.4 years. Early diagnosis and early surgical
management of patients with carcinoid heart disease may provide the best results.
Wellens' Syndrome: Critical to Recognize
Eric Wilkerson MD, Ishan Mehta MD, Hamza Shah MD, Aravind Sekhar MD, Prafull
Raheja MD, Rita Coram MD
Wellens’ Syndrome has been clinically defined as electrocardiographic manifestation of proximal left
anterior descending (LAD) coronary artery stenosis. Early identification of the Wellens
electrocardiogram pattern is of paramount importance to prevent extensive anterior wall infarction.
Described is a case of typical Wellens’ Syndrome changes with critical stenosis of the distal left main
A Double Whammy Fungal Sphenoid Sinusitis with Cranial Nerve Palsy
First Author: Ali Baghian MD, Zachary Marks MarkAlain Dery DO, MPH, Steven Zuckerman MD,
Introduction: The occurrence of isolated sphenoid sinus disease has decreased since the widespread
use of antimicrobials, accounting for 3% of all sinus infections. The most commonly reported
manifestation of sphenoid sinus disease is headache, while other symptoms typically seen with sinusitis
such as rhinorrhea and cough are usually absent; visual disturbances are the second most common
complaint. Our case illustrates a rare presentation of sphenoid sinusitis with Aspergillus species causing
right cranial nerve VI palsy.
Case: The patient is a 60 year old woman presenting with three days of right frontal headache and
double vision. She noted this was most apparent with looking towards the right. Past medical history
was significant for a 6 year history of well controlled diabetes mellitus and Hepatitis C for which she was
being treated with ribavirin and pegylated-interferon. Her neuroopthalmological exam was remarkable
for a complete inability to abduct her right eye. All other findings were normal. Preliminary non-contrast
CT revealed heterogenous opacification of the left sphenoid sinus compatible with fungal sinusitis.
Magnetic Resonance Venogram did not indicate any evidence for a Cavernous Sinus Thrombosis.
Lumbar puncture revealed a normal opening pressure and normal CSF analysis. Otolaryngology was
consulted and medical treatment was initiated simultaneously with parenteral amphotericin B and
levofloxacin. The following day she underwent left transnasal endoscopic sphenoidotomy, and tissue
pathology showed branched hyphae consistent with Aspergillus (unspeciated), without evidence of bony
invasion. Postoperative evaluation confirmed a full recovery from headache; however, unilateral
abducens palsy persisted. Antimicrobial therapy was de-escalated and she was discharged home. Sixweek outpatient follow up verified normalization of her lateral rectus defect
Discussion: Isolated oculomotor nerve palsies are a known complication of diabetes mellitus and are
thought to represent nerve involvement on an ischemic basis. However, in our patient VIth nerve palsy
was found to be the result of an Aspergillus sphenoid sinus infection. Fungal sphenoid sinusitis is rarely
the cause of an isolated abducens nerve palsy, raising the possibility that this entity is underreported. In
contrast, while isolated sphenoid sinus disease is also a rare entity, abducens nerve palsy has been
documented as the second most common finding on presentation. Therefore, in patients who present
with headache and ocular palsy, fungal sphenoid sinusitis should be considered, especially in the setting
of immunosuppression. Based on data collected from small retrospective case studies, surgical
intervention within 72-96 hours is recommended, and although this approach provided excellent results
in our case, more evidence is required to substantiate an optimum modality and timeframe for
Rapidly developing endocarditis and recurrent septic arthritis in a patient
with Abiotrophia bacteremia
First Author: Yasin A. Khan, MD, Amanda Jimenez, MD, Brett Martin, MD, Lise Murrell, BS, Alvaro Garcia,
MD, Bharat Sachdeva, MD, Adrian Sequeira, MD
Abiotrophia species, formerly known as nutritionally variant streptococci, accounts for 1-2% of blood
culture negative endocarditis. The difficulty in culturing this organism and the high treatment failure
rate contribute to a significant level of morbidity. We present a case of a patient with Abiotrophia
bacteremia who failed initial antibiotic therapy and later presented with multi-valve endocarditis.
A 51 year old African American female with hypertension on chronic hemodialysis (HD) via a left upper
extremity arterio-venous graft presented with three days of fever and left wrist pain. Physical
examination was significant for tenderness and limited range of motion at the affected wrist.
Investigations revealed a leucocytosis while X-ray of the wrist revealed sclerosis and narrowing of the
joint. Arthrocentesis was performed; gram stain and culture were negative with no leukocytes. Blood
cultures reported gram-positive cocci in chains which were identified as Abiotrophia species. As it
resides in the oral cavity, the oral-maxillofacial surgery (OMFS) service was consulted but found no
pathology. Due to the correlation between Abiotrophia and endocarditis, a transesophageal
echocardiogram (TEE) was performed which was negative. The patient was started on cefazolin and
responded well with resolution of leucocytosis and with sterile repeat blood cultures; she was
prescribed a 2 week course of oral amoxicillin and clavulanate on discharge.
Six weeks later, she presented with fever and right knee pain. Exam revealed a tender swollen right
knee. Blood cultures were positive for Abiotrophia species. The patient was started on intravenous (IV)
ampicillin and gentamicin. On arthrocentesis, the fluid was turbid with >140,000 cells, though gram stain
and culture were negative. Because of recurrent bacteremia, a repeat TEE was performed and revealed
vegetations on the aortic, mitral and tricuspid valves. In order to evaluate the HD access graft for
possible infection an indium-tagged white blood cell scan was performed which revealed increased
uptake only in the right knee. Repeat blood cultures were negative following in-patient treatment. She
was also prescribed 6 weeks of IV antibiotics upon discharge.
Compared to streptococci, endocarditis caused by Abiotrophia species is characterized by greater
complications. Increased virulence is secondary to exopolysachharide production and long generation
time. The organism enjoys affinity for avascular structures. This case was presented to increase
awareness and illustrate the pathogenic nature of the organism.
The New AIDS Chameleon?
Tracey L. Henry, MD, MPH, MS, Stacy Newman, MD, Alvah T. Wickboldt, Jr. MD, Leonardo Seoane, MD,
Introduction: Nocardia asteroides and Cryptococcus neoformans are common opportunistic infections in
the HIV/AIDS population and those with other forms of immunosuppression. While most primary
immunodeficiencies are discovered in early childhood; there are immunodeficiencies which present in
late adulthood, such as complement deficiencies, common variable immunodeficiency, isolated CD4
lymphopenia and the recently characterized adult-onset immunodeficiency.
Case Presentation: A fifty-eight year old African American female with type II diabetes mellitus (HbA1C
8.6%) and remote history of N. asteroides brain abscesses presented with generalized weakness,
lethargy, mildly slurred speech and a left sided facial droop. Additionally, she had an associated
headache with confusion worsening over days to weeks. Her only home medication was insulin detemir.
Stroke protocol was initiated by the emergency department. An MRI demonstrated diffuse nodular
leptomeningeal enhancement within the posterior fossa and left facial nerve enhancement at the
cerebellopontine angle, without evidence of mass effect or infarction. Serum studies revealed WBC
3,890 cells/mm2 (neutrophils 82%, lymphocytes 5.2%). CSF analysis revealed WBC 1,388 cells/mm2
(neutrophils 94%), protein 177mg/dl, glucose 196mg/dl, opening pressure 24 cm H2O and an elevated
cryptococcal antigen titer of 1:128. Blood and CSF cultures both resulted in heavy growth of C.
neoformans. Absolute CD4 count was 80 cells/µl (CD4 was 403 during prior N. asteroides infection). Her
HIV ELISA and Western blot were both negative, and complement, immunoglobulins, and CD3, 19, 20,
and 45 were unremarkable. Eighteen days of liposomal amphotericin B and flucytosine were
administered followed by fluconazole. A decision was made to check her serum gamma interferon
autoantibody (IFN-gamma) level which was elevated at 1.5 pg/ml (normal < 0.3). Given her multiple
opportunistic infections, repeated negative HIV testing, negative immunological workup, and elevated
IFN-gamma autoantibody, the patient was diagnosed with adult-onset immunodeficiency.
Discussion: Recently described cases suggesting a new, cell-mediated immunodeficiency distinct from
HIV/AIDS presented with nontuberculous mycobacterium and disseminated fungal and viral infections.
Unlike HIV/AIDS, it is not a virus, but is a noninfectious etiology likely triggered by environmental and
genetic factors. Subsequently, an association between elevated IFN-gamma autoantibodies and severe
opportunistic infections in a presumed normal host has been termed adult-onset immunodeficiency.
While previously described patients with these characteristics were living in Southeast Asia or of Asian
descent, our patient is an African American living in southeastern USA. This case stresses the significance
of looking for other primary immunodeficiencies in a HIV-negative, non-immunosuppressed patient with
repeated opportunistic infections. Identifying adult-onset immunodeficiency is critical as there are
proposed treatments including the use of therapeutic monoclonal rituximab to target B cells which
produce IFN-gamma autoantibodies.
First Author: Abhishek Seth, MD Saurabh Rajpal,MD Taru Saigal,MD Shawn Milligan,MD
INTRODUCTION: Back pain is the second most common neurological ailment in the United States and
accounts for 2.7 million emergency room (ER) visits annually. Early diagnosis of a serious underlying
pathology for back pain is important to avoid catastrophic neurologic sequelae. Spontaneous spinal
epidural hematoma (SSEH) is a rare neurosurgical emergency, the diagnosis of which is challenging as it
is often based on clinical presumption.
CASE REPORT: A 30-year-old female with no prior medical history, presented to the ER for back pain
three times in a span of 72 hours. Two days prior to admission, the patient had her first episode of back
pain which lasted 5 minutes. Pain was 10/10 in severity and involved mid to lower back. She denied
fevers, chills or trauma. The pain recurred in the evening and she visited the ER. CT of abdomen did not
show renal stones and an ultrasound of the gall bladder was negative for gallstones. She was prescribed
pain medication and discharged home. Another episode of back pain occurred the next day which
prompted her return to the ER. She also complained of urinary hesitancy. This was attributed to opiate
use and the patient was discharged home. The next day, she returned to the ER with back pain and
urinary retention. She denied weakness, tingling or numbness of any extremity. Examination revealed
thoracolumbar paraspinal tenderness. Radiograph of thoracolumbar spine showed mild scoliosis but no
fractures. MRI Spine revealed a soft tissue epidural mass compressing the posterior aspect of the spinal
cord in T4-7 region. Neurosurgery was consulted and she was started on intravenous steroids and
antibiotics for possible epidural abscess. She was taken to the operating room. An epidural hematoma
compressing the cord in T4-7 segments was found. Resection of hematoma and thoracic laminectomy
was performed. Post-operative course was uneventful and there was marked improvement in her back
pain. Urinary symptoms resolved and she was discharged with neurosurgery follow up.
DISCUSSION: SSEH is a rare pathologic entity. Most SSEH are characterized by abrupt pain around the
involved vertebrae and variable neurological deficits depending on the site of the hematoma. Treatment
ranges from conservative management to emergent neurosurgery depending on extent of neurological
involvement. Even though most cases of back pain are benign, careful clinical assessment and
recognition of “red flags” in ER is essential for diagnosing ominous causes.
A Little Short of Breath: A Case of Cardiac Tamponade from an Uncommon
First Author: Elizabeth Laura Herrle, MD
Introduction: Cardiac tamponade is a potentially life-threatening condition with a broad differential.
Prompt recognition and management of this disorder is essential, and the clinician must identify the
underlying etiology of tamponade as this disorder can be the first manifestation of many systemic
Case Presentation: A previously healthy 51 year old Caucasian woman with history of congenital
deafness presented to an outside hospital emergency department with one week of progressive fatigue,
dyspnea and mild cough exacerbated by cold air. The patient had not received any healthcare in
approximately eight years. Computed tomography scan performed at the outside hospital emergency
department revealed a massive pericardial effusion. The patient was transferred to our institution for
further evaluation and management. The patient was hemodynamically stable on arrival with heart rate
of 65 and blood pressure 165/96. A paradoxus of 20 mmHg was recorded. Physical examination was
notable for jugular venous distension to the mandible, distant heart sounds, bilateral mild lower
extremity edema and absence of breath sounds in bilateral lower lung fields. Electrocardiogram showed
low limb lead voltage. Echocardiography confirmed the presence of a large pericardial effusion with
evidence of right ventricular collapse in diastole. Diagnostic and therapeutic pericardiocentesis was
performed with removal of 1500 milliliters of straw-colored fluid. The patient tolerated the procedure
well, and her symptoms resolved after pericardiocentesis. Pericardial fluid analysis showed no evidence
of infection or malignancy. Renal function as measured by serum creatinine was normal. Erythrocyte
sedimentation rate and c-reactive protein levels were normal. An anti-nuclear antibody titer was normal
at 1:80. Thyroid stimulating hormone level was greater than 100, above laboratory assay limit, with a
free thyroxine level of 0.04 ng/dL and a total triiodithyronine level below the detectable limit of our
assay. Anti-thyroperoxidase antibody titer was strongly positive. Our patient was diagnosed with severe
Hashimoto’s thyroiditis complicated by pericardial effusion with tamponade. Interestingly, she did not
have other typical features of myxedema. She was treated with oral levothyroxine therapy with
therapeutic suppression of thyroid stimulating hormone. Follow up echocardiography 3 months after
discharge showed no evidence of recurrent pericardial effusion.
Discussion: Hypothyroidism is commonly associated with the formation of mild to moderate pericardial
effusions which are rarely symptomatic. However, cardiac tamponade as a result of hypothyroid
pericardial disease has rarely been reported in adults, with only twenty-two reported cases in the
literature. It is important to identify this atypical presentation of hypothyroidism to prevent both the
recurrence of pericardial effusion and the development of the many other significant adverse effects of
severe hypothyroidism. Clues to the diagnosis in this case included precipitation of symptoms in cold
weather and relative bradycardia in the setting of tamponade as well as her risk factors for undiagnosed
hypothyroidism which include her age, gender, and lack of regular health care.
A Case of Gadolinium-Induced Kounis Syndrome
Michael Allison, MD
Introduction: Acute allergic myocardial infarction, also known as KounisSyndrome, is part of the
spectrum of acute coronary syndromes. The release of inflammatory mediators duringan allergic or
hypersensitivity reaction can cause coronary vasospasm andplaque rupture.
Case Presentation: A 55 year old manwith hypertension, obesity, and tobacco use presented for
outpatientcontrast-enhanced magnetic resonance imaging of the brain to evaluate possibletrigeminal
neuralgia. After the initial contrast bolus, the patient becamenauseated, diaphoretic, and lethargic. He
was transferred immediately from theradiology suite to the emergency department.Vital signsincluded
blood pressure 62/23 mmHg and heart rate 110 beats per minute. Cardiacexamination revealed regular
rate and rhythm, no murmurs or gallops, and anon-displaced point of maximal impulse. He was
resuscitated with crystalloidfluids, and standard therapy for an allergic reaction. After receiving
subcutaneousepinephrine, intravenous diphenhydramine, and intravenous methylprednisolone
thepatient’s blood pressure improved. As he became more alert, the patient began complaining of left
sided chest pressure. Anelectrocardiogram showed inferior ST segment elevations with reciprocal
STsegment depressions in the lateral leads. The patient was taken emergently tothe cardiac
catheterization laboratory, where he was found to have a proximalright coronary artery (RCA) thrombus
without evidence of plaque rupture and anocclusive mid-RCA thrombus with evidence of plaque
rupture. A bare metal stentwas placed at each site. Echocardiographyimmediately after the procedure
revealed inferior wall hypokinesis, whichresolved on repeat imaging one day after stenting. Serial
troponin levelsincreased from 0.02 ng/mL at the onset of chest pain to 32 ng/mL at the time ofcardiac
catheterization. Kounis Syndromewas first described in the literature in 1991. Acute coronary syndrome
after anallergic reaction has been reported in patients with food allergies, asthma,urticaria, and
angioedema as well as medication induced reactions from antibiotics,iodinated contrast media,
corticosteroids, and tetanus toxoid. After a thoroughreview of the literature, this appears to be the first
case of Kounis Syndromeassociated with gadolinium use. The proposed mechanism involves coronary
arteryspasm and plaque rupture due to mast cell degranulation.
Discussion: Therapy involvesstandard treatment for an acute coronary syndrome. In patients who
developchest discomfort in the setting of an acute allergic reaction, a high index ofsuspicion should be
maintained for acute allergic myocardial infarction.
Doc! There is something in my eye!
Namrata Shah MD, Samad Rasul M.D., Jhansi Gajjala MD
Howard University Hospital, Department of Internal Medicine, Division of Infectious Diseases,
Washington DC
Introduction: Infections of the eye can be caused by various organisms.Infections by
parasites,especially adult worms,circumnavigating the eye are few and numbered,such as Loa Loa,
Mansonella perstans,Dirofilia repens ,Wucheria bancrofti and Thelazia callipaeda.
Case Presentation: Wedescribe a case of Loa Loainfection of the eye, which is a frequent cause of Adult
parasitosis, butrarely seen in the United States. This is usually seen in African immigrants. Infection is
transmitted through the bite of the African deer fly (genusChrysops). Rarely, absence of microfilaria in
blood smears and nonspecific symptoms make the diagnosis difficult. Keen physical exam can clinchthe
diagnosis as in our case. A22 year old female, recent immigrant from Cameroon presented to the
emergency roomwith the chief complaint of eye discomfort. She described an intermittentsensation of
something moving across her eye that lasted for two days Shedenied eye pain, vision changes or eye
trauma. She had no history of similarsymptoms in the past. Review of other systems was
unremarkable.Ofnote, her mother and aunt also had similar complaints in the past. Patient wasborn in
Cameroon and had migrated to the United States 6 months ago. Noexposure to sea food/uncooked
meat/pets or animals was noted. Patient wasafebrile and hemodynamically stable and physical exam
was otherwise normal. Laboratorytesting was unremarkable except for a high eosinophil count. (46%)
However, oncareful examination of the left eye, a 35 mm long adult worm was noticed migratingacross
the subconjunctiva. The patient was rushed to the operating room for an extractionof the worm, but the
worm withdrew itself.Lookingat the morphology, the infectious diseases team identified it as Loa Loa.
Slit lamp exam was normal and thick and thin smears during daytime were negative for microfilaria. PCR
for Loa Loa was negative. Skin snips werenegative for Onchocerciasis and thepatient received a 21 day
course of Diethylcarbamazine after pretreatment withsteroids which was tolerated well with
amelioration of symptoms. A follow upexam, 30 days later was unremarkable.Highestincidence of
Loaiasis is seen in Cameroon, Republic of Congo, Central AfricanRepublic, Nigeria, Gabon and Guinea.
The deer fly is attracted by movement ofpeople and wood fires, detected by their
chemoreceptors.Travelerswho stay in these areas for long periods of time are also at risk. With theever
changing world, and increased globalization, physicians in the UnitedStates, should be aware of this
disease etiology and should be on the look outfor this inconspicuous complaint of something in the eye,
especially inAfrican immigrants.
Discussion: Our literature search revealed 15 cases all over the U.S. of which 5 were reportedfrom the
District of Columbia. In conclusion, keen physical examination andrespect for the patient’s complaints
will aid in clinching this rare diagnosis.
Alejandro Velez Garza, MD
A Suffocating Bleed
Jorge Alejandro Velez Garza MD, Associate, Jaime Alejandro Hernandez Montfort MD, Gina Luciano MD,
Department of Medicine, Baystate Medical Center, Springfield MA.
Pulmonary vascular enlargement is a common physiologic change in patients with chronic
thromboembolic pulmonary disease (CTED). Early recognition of this condition in the setting of massive
hemoptysis can prompt emergent and life-saving embolization procedures.
A 62 year-old gentleman presented to our emergency department after an acute episode of massive
hemoptysis. He had experienced moderate hemoptysis over the past 5 years with worsening of his
symptoms over the past month. The patient reported a history of CTED since 1969 with inferior vena
cava clipping and subsequent chronic warfarin therapy. With a strong family history of thrombophilia,
the patient had been worked up for hypercoagulable disease but was determined to have idiopathic
hereditary thrombophilia after thorough testing. Pertinent exam findings included stable vital signs,
bibasilar crackles and no signs of volume overload. Laboratory investigations revealed hemoglobin of
13.9 mg/dl and INR of 3.0. Echocardiogram showed a severely dilated right ventricle and decreased
systolic function with an estimated pulmonary artery pressure of 85 mmHg. CT angiogram imaging
revealed abnormal appearance of bronchial arteries with marked tortuosity, no A-V shunting and
chronic occlusion of the right middle and lower lobe pulmonary artery branches. After 2 additional
episodes of massive hemoptysis, emergent bronchoscopy was done. There was right and left main
bronchus blood pooling with persistent oozing after 500 cc of fresh blood was suctioned. An acute drop
in the hemoglobin to 10 mg/dl prompted ICU transfer where the patient received a packed RBC
transfusion and was later transferred to interventional radiology for bronchial artery embolization with
improvement of his condition. Acute management of this patient was successful, but a definitive
solution will require more aggressive and hazardous therapeutic measures for CTED such as pulmonary
Bronchial artery blood volume can increase from the norm of 1 to 2% of the cardiac output to 30%(1) in
patients with chronic thromboembolic disease, which significantly increases the probability of lifethreatening bleeding. Early recognition of bronchial artery hemorrhage can aid clinicians on critical
decision making regarding initial aggressive therapeutic measures such as IR bronchial artery
embolization. In the long term, pulmonary thromboendarterectomy remains the surgical procedure of
choice in patients with CTED and severe pulmonary hypertension with a reported mortality of 4 to
7%(2). Favorable hemodynamical outcomes have been reported with mean reduction in pulmonary
vascular resistance of 70%(3). Although not reported yet, right heart hemodynamical improvement in a
patient with recurrent episodes of massive hemoptysis from CTED may decrease the probability of
Endrys J, Hayat N, Cherian G, Comparison of bronchopulmonary collaterals and collateral blood flow in patients with chronic
thromboembolic and primary pulmonary hypertension, Heart 1997; 78:171-176.
Jamieson SW et al, Pulmonary endarterectomy: experience and lessons learned in 1,500 cases, Ann Thorac Surg 2003; 76:14571464.
Auger WR, Fedullo PF, Chronic thromboembolic pulmonary hypertension, Semin Respir Crit Care Med 2009; 30: 471-483.
Phillip, MD
What Happened To My Hands and Feet? A Case of Hand Foot Syndrome
Tarik Phillip, MD, Sheila Sungurlu, MD, Nour Abdul-Baki, Anil Sil, MD, FACP
Hand foot syndrome (HFS) is a cutaneous side effect associated with many chemotherapeutic agents.
The exact pathophysiology remains unknown and the best therapy appears to be the cessation of the
drug or the reduction in dose. Rarely is hospitalization required if detected early but if ignored it may
result in a debilitating condition. We report such a case of stage 3 HFS associated with taxotere whose
initial symptoms went untreated.
A 53 y/o female with a history of invasive ductal carcinoma of the right breast presented to the ER with
a painful, erythematous and desquamating rash encompassing the sole of her feet and the palm of her
hands. Further investigation revealed that the patient had started taxotere a week prior and had
developed some erythema and numbness of the plantar surface. This was not explored further and
within 24-48 hrs her symptoms had become debilitating to the point where it was extremely difficult to
walk or touch objects secondary to pain rated 10/10. She was started on solumedrol, vit.B6 and dilaudid.
Within two days her symptoms had improved and she was d/c. The patient was seen two months after
and her symptoms had completely resolved.
The most feared complication of taxotere is myelosupression but one cannot underestimate the
debilitating effects of the less known side effect of hand foot syndrome especially if not treated early.
Clinicians need to be aware of the association of this drug and HFS and the early manifestations of this
potentially debilitating syndrome.
Morrow, MD
AIDS Masquerading as Dermatomyositis: Underscoring the Importance of
Sexual History
Shauna Morrow, MD
Introduction: The sexual history continues to be one of the mostunreliably obtained components of the
medical interview in primary caresettings, leading to lost opportunities for appropriate STI
(sexuallytransmitted illness) screening as well as counseling regarding safe sexualpractices.
Case Presentation: In this case, obtaining aroutine sexual history may have prevented a delay in
diagnosis of HIV andsubsequent AIDS. A 53-year old man withlongstanding diagnosis of amyopathic
dermatomyositis was admitted to thehospital for evaluation and treatment of steroid unresponsive
interstitial lungdisease. On admission, the patientdemonstrated significant hypoxia (oxygen saturation
74% on room air) withperipheral cyanosis and moderate respiratory distress. The patient was admitted
to the ICU forrespiratory support with NPPV (noninvasive positive pressure ventilation) andintravenous
steroids. CXR revealeddiffuse ground glass opacities thought to be consistent with interstitialpulmonary
disease. However, given thepatient''s deteriorating respiratory status, ongoing weight loss, and lack
ofsupport for the diagnosis of dematomyositis (negative ANA, ENA and anti-Jo 1,skin biopsy
nonspecific), an alternative etiology was suspected. Sexual history taking revealed that patienthad
several sexual encounters with male partners 5 years prior. HIV screening was positive and CD4 count
was9/cu mm. The patient was empiricallytreated for Pneumocystis pneumonia,which was later
confirmed by biopsy obtained during bronchoscopy. The patient was also found to have CMVviremia
and was treated with valganciclovir. With appropriate management, his condition improved and he was
dischargedfrom the hospital. HAART (highly activeantiretroviral therapy) was initiated and patient's CD4
count rebounded. This case illustrates the importance ofobtaining a sexual history in all patients,
including those perceived to be lowrisk.
Discussion: This patient was a husband and a father, which may have contributed to failure to obtain a
sexual history. Recent studies indicate that the sexualhistory is often omitted in the primary care
setting; only 35% of PCPs (primarycare providers) state that they often (75% of the time) or always take
a sexualhistory (1). Physicians cite several factors, including embarrassment and timeconstraints, as
reasons for excluding discussion of sexual health. An adequate sexual history should
includedocumentation of sexual orientation, previous and current sexual partners, sexualpractices, and
use of barrier protection. The sexual history is an underutilized and cost-effective means to
earlydetection of STIs as well as a gateway to discussion of safe sexual practicesand behavioral risk
1. Nusbaum MRH, Hamilton CD. The Proactive SexualHistory. Am Fam Phys 2002; 66: 1705-12.
Horne, MD
A Sheep in Wolf’s Clothing: A Case of Pseudovasculitis
Amanda M. Horne, M.D., Sarah M. Gaugler, D.O., Kenneth Ball, M.D., Joe Pressler, M.D., Albert
Dreisbach, M.D., Vikas Majithia, M.D.
Introduction: Pseudovasculitis is difficult to distinguish from “true”vasculitis as it mimics the many
clinical and laboratory findings. Theetiologies are as varied as the manifestations and include
infections,malignancies and illicit drugs as the top 3. We report a patient withpseudovasculitis
associated with methamphetamine use.
Case Description:A 27-year-old Caucasian female presented with 2-weekhistory of non-productive
cough, dyspnea, and fever. Review of systems wasnegative except for arthralgias. Pertinent positives on
past medical, family and social history includedanxiety, current smoking (10 pack-years). She denied
alcohol or illicit druguse. Systemic examination revealed stable vitals, no distressand significant
abnormalities only of dried oropharyngeal blood and bilateralcrackles on lung exam. Abnormal
laboratory studies were serum creatinine 2.5,hematocrit 16.9, elevated LFTs, ESR 60 mm/hr, CRP 25.1
mg/dl and urinalysisshowing proteinuria and hematuria. CXR showed bilateral patchy infiltrates.
CTthorax revealed multiple bilateral patchy ground-glass densities.She was admitted with the clinical
impression of atypicalpneumonia versus vasculitis (pulmonary-renal syndrome). Antibiotics and pulseIV
solumedrol were started. Further testing showed normal CPK, ANA, ANCAs,Hepatitis panel, HIV, AntiGBM, ASO, APLS, C3, and C4. Blood and urine cultures were negative. Bronchoalveolar lavage was nondiagnostic. Renal biopsyshowed acute tubular necrosis and fibrinoid change without vasculitis. With
anegative work-up, steroids were discontinued and she was discharged on 12thday of hospitalization.
Two days later, she returned to the ER after witnessedseizure activity, where-by family reported use of
methamphetamine. MRI brainshowed extensive changes typical of vasculitis, which resolved on repeat
MRI.All the previously abnormal laboratory studies had returned to normal. Sheadmitted to current and
previous use of methamphetamine and UDS was positivefor amphetamines. Our final diagnosis became
methamphetamine-induced pseudovasculitis.
Discussion: Cases of pseudovasculitis associated with drug use havebeen reported in the literature
however the majority of cases are attributed tococaine. Methamphetamines,however, have been
shown to have many of the same toxic effects of cocaineincluding vasculitis. This casedemonstrates the
difficulties in differentiating a “true” vasculitis from adrug-induced pseudovasculitis. It highlights the
importance of thisdistinction, particularly concerning treatment. Many times withdrawal of the
offending drug alone can besufficient for resolution of symptoms. Accordingly the patient was
discharged with improvement inher pulmonary, renal and neurologic dysfunction without the need
Meningoencephalitis: A rare presentation of undiagnosed Adult Still’s Disease
Shariq Shamim, MD Richard Lustig, DO Kwasind Huston, MD
Introduction: Adult still’s disease (ASD) is a rare multisystem disorder. CNS involvement is rare in
the disease with only six reported cases involving meningoencephalitis. Here we describe a patient
who presented with meningoencephalitis as an initial manifestation of ASD which, to our knowledge,
is the first such report.
Case Presentation: We present a 34 year old female hospitalized with altered metal status who a
week ago was treated for aseptic meningitis at an outside hospital. After discharge she developed
progressive lethargy and inability to identify family members. She had fever of 100.9 with positive
Kernig’s Sign. Work up with CT Head and Lumbar Puncture was negative. She continued to have fever
daily, mostly in the evenings despite 5 days of treatment with IV Ceftriaxone, Vancomycin, and
Acyclovir. Brain MRI showed non specific FLAIR intensities. Extensive laboratory work up was
negative. Observation of having daily,mostly in the evening time, having rash at the time of fever
lasting for few hours, lead to the clinical suspicion of ASD. She met both Yamaguchi criteria and Cush
Criteria for ASD. After starting on IV methylprednisone and discontinuing all antimicrobials her fever
subsided. She was discharged on prednisone taper, was later put on methotrexate on follow up at the
clinic due to recurrence of symptoms.
Conclusion: For patients with meningitis or meningoencephalitis, particular attention has to be given
to the timing and frequency of the fever. If fever is quotidian and mostly occurs in the evening, ASD
should be considered in the differential especially if the fever does not resolve with appropriate
Boghdadly, MBBCh
Zeinab El Boghdadly, MD, Deborah Asnis, MD
INTRODUCTION: Ketamine is used inanesthesia and pain control in palliativecare settings. It ispopular
as a recreational drug in dancingclubs and rave partiesin Asian communities, known as SuperK, Vitamin
K and SpecialK. It is sold as a dried white powder; itmay be injected,ingested or smoked. Ketamine
causespsychologicaldissociation, rapid respiratory and cardiac rates,nausea and vomiting,hallucinations
and seizures. In 2007,Shahani identified a newclinical syndrome in 9 ketamineabusers who
developedurinary symptoms, ketamine associated ulcerative cystitis (KAUC). Presentationsincluded:
dysuria,frequency, urgency, and hematuria withsterile urine cultures.Initially, reports were from Asia;
now ithas entered the New Yorknightclub scene. Early recognitionby physicians isimportant because of
the deleteriousurological effects.
CASE PRESENTATION: A 23 year old Chinesemale presented with left flank pain, urgency,decreased
urine outputand hematuria for two days. Pastmedical history wassignificant for recurrent urinary
tractinfections over twoyears occurring simultaneously withweekly intranasal use ofKetamine. On
examination, he wasafebrile with left flankand suprapubic tenderness. Whiteblood cell count
was14,000, creatinine 1.3 mg/dL and urea 9mg/dl. Urinalysis showedWBC> 50, RBC>50 but
negativenitrites. Urine andblood cultures were negative. CT scan of theabdomen and pelvisshowed
bilateral hydronephrosis andhydroureter withcollapsed bladder. Recent cystoscopyshowed
contractedthickened bladder wall with decreasedcapacity. Bladder biopsyrevealed fibromuscular tissue
withmild acute and chronicinflammation, degenerated urothelialcells with mild atypia.The patient was
discharged onPentosan polysulfate andsolifenacin for hyperactivebladder and counseled todiscontinue
use of ketamine.
DISCUSSION: Ketamine is a N-methyl-D-aspartate( NMDA ) receptoranatogonist. Ketaminemetabolites
are renally excreted withhalf life of 2-3 hours.Inhaled ketamine works in 10 minutes.Consumers report
out ofbody trip (k hole journey), neardeath experience,intense detachment and
visualhallucinations.Urological symptoms have been detected inabout 20% of ketamineabusers. The
pathophysiology of KAUCis unknown but severalmechanisms have been suggested: 1)direct toxic effect
ofketamine or its metabolites (e.g.norketamine ) on thebladder wall 2) microvascular andischemic
changes, 3) anautoimmune reaction triggered by thedrug or its metabolites.Cessation of ketamine
remains thecornerstone oftreatment. Physicians should consider KAUC inyoung adults withurinary
complaints and sterile pyuria andquestion them thoroughlyabout recreational drugs.
Gentry III, MD
Death Delusions and Myoclonus in a Dialysis patient with multi-dermatomal
Herpes Zoster: a consequence of disease or treatment?
First Author: James L Gentry III, MD; Second Author: Cecily Peterson MD, FACP
Introduction: Valacyclovir toxicity, an avoidable medication error is seen primarily in patients with
renal insufficiency. Presenting symptoms are neuropsychiatric and include disturbances in
consciousness, myoclonus, seizures, comas, and death delusions.
Case Description: A 65 year old woman with end stage renal disease was diagnosed with a multidermatomal herpes zoster infection and prescribed valacyclovir 1 gram every 8 hours. After 24 hours
and 4 grams of valacyclovir, the patient began to develop emotional lability, delusional thoughts of
death, and agitation. Her level of consciousness declined to minimal responsiveness.
Upon presentation to the Emergency Department, her GSC was 10, temperature 38.4C, blood
pressure 192/84, heart rate 113, and oxygen saturation 100% on 4 liters oxygen by nasal cannula. The
patient received empiric broad-spectrum IV antibiotics, and 1 gram IV acyclovir. A CT brain revealed no
acute intracranial process. Lumbar puncture showed a colorless sample with cell count of 2, negative
gram stain, normal glucose and normal protein levels. Valacyclovir neurotoxicity was then suspected.
Nephrology was consulted for immediate dialysis which was performed daily for four consecutive days
of 6-hour sessions. After 2 sessions, the patient demonstrated intermittent alertness with near full
orientation. The patient returned to her cognitive and functional baseline by hospital day 5 and was
discharged home.
Confirmatory testing of valacyclovir induced neurotoxicity was performed using serum and CSF
samples. These samples revealed levels of acyclovir and the acyclovir metabolite 9carboxymethoxymethylguanine (9-CMMG)at four and a half times greater than the median
symptomatic drug level. CSF 9-CMMG level determination is the gold standard to confirm acyclovir
induced neurotoxicity.
Discussion: Altered mental status in the setting of valacyclovir use for herpes zoster infection creates a
diagnostic dilemma between drug toxicity and viral encephalitis. Certain symptoms have increased
specificity for valacyclovir toxicity, including myoclonus and neuropsychiatric symptoms such as death
delusions. Combining these symptoms and proper medication reconciliation with the clinical context
results in prompt recognition of drug toxicity and improved clinical outcomes. The diagnosis is
confirmed by CSF 9-CMMG levels as acyclovir levels are less reliable. Given the poor access 9-CMMG
testing, clinical recognition including identifying the risk factor of renal insufficiency is essential. This
case underscores the importance of careful prescribing in renal failure patients.
Takotsubo (Stress-induced) Cardiomyopathy in an incarcerated patient
presenting with methadone withdrawal.
First Author: Ujjval Jariwala, MD Second Author: Shyam Kapadia, MD Third Author: Yingwei Qi, MD
Introduction: We describe a unique case of Takotsubo (stress-induced) cardiomyopathy in an opioiddependent patient who was imprisoned for one week and presented with signs/symptoms of opioid
withdrawal. To our knowledge there is no reported case of takotsubo cardiomyopathy in an
incarcerated patient and only three reports of it being associated with opioid withdrawal.
Case description: A 45 year old female with past medical history of steroid dependent polyarticular
juvenile rheumatoid arthritis, depression, anxiety, peripheral vascular disease, cellulitis and
osteomyelitis of foot, who was incarcerated one week prior, was transferred from detention center to
hospital because of lethargy, diarrhea and stool incontinence for few days. Her home medications
included prednisone (10mg/day), methadone (30mg/day), oxycodone, clonazepam and antibiotics for
At the time of admission, she was arousable only to stimulation, hypotensive, tachycardic, and
tachypneic. Laboratory studies showed elevated white cell count, hyponatremia, elevated BUN and
creatinine, non-anion gap metabolic acidosis (indicating dehydration secondary to diarrhea), normal TSH
and total cortisol of 43.3mcg/dl. Imaging studies of head, chest and abdomen were unremarkable.
Medical records requested from detention center showed that while in prison, prednisone, clonazepam,
and opioids were stopped and she was only treated with Librium for benzodiazepine withdrawal.
Methadone withdrawal was considered the most likely diagnosis in the patient.
After initial improvement, on day 3 of hospital stay she was noted to have worsening shortness of
breath with hypoxia and new pulmonary edema on chest radiography. Her EKG showed diffuse T-wave
inversion in anterolateral and inferior leads, with marked QTc prolongation. She also had modest
elevation in Troponin T and CK-MB, and very high Pro-BNP levels. Echocardiography showed severely
hypokinetic mid to distal anterior wall, distal septum and apex relative to other segments. Patient was
transferred to another hospital and underwent urgent cardiac catheterization, which showed nonobstructive coronary arteries. Patient was diagnosed as having takotsubo cardiomyopathy and was
treated accordingly for heart failure. Repeat echocardiography few days later showed improvement in
left ventricular function.
Discussion: Takotsubo cardiomyopathy is characterized by transient systolic dysfunction of apical and/or
mid segments of left ventricle, which mimics myocardial infarction, but there is absence of obstructive
coronary artery disease. It is typically triggered by acute medical illness or by intense emotional or
physical stress. This case highlights the rare but serious possibility of developing stress cardiomyopathy
in patients on chronic opioids who have withdrawal after being incarcerated.
Rehman Meeran, MBBS
IL2 induced AV Dissociation
First Author: Talha Abdul Rehman Meeran, MBBS Second Author: Kim Reiss, MD Mentor: Mohammed
Abuzahra, MD
Introduction: Recombinant Interleukin-2 (rIL2) is approved by FDA for the treatment of metastatic renal
cell carcinoma and metastatic melanoma. rIL2 is commonly associated with cardiac toxicity including
arrhythmias (classically tachyarrhythmia), hypotension and myocarditis. This case report describes a
case of A-V dissociation and resultant junctional escape rhythm associated with rIL2 therapy.
Case Presentation: 51 year old Caucasian woman with recently diagnosed metastatic melanoma was
admitted for initiation of Cycle 1 of high dose rIL2 chemotherapy. She was a non-smoker and did not
have any other medical co-morbidity. She had a normal stress echocardiogram one week prior to
admission. Her home medications included a multivitamin and an anxiolytic on as needed basis. After
receiving the second dose of rIL2, she complained of fluttering sensation in the chest associated with
lethargy and rigors. Her symptoms resolved with Morphine, which is commonly given for rigors
associated with rIL2. Systolic blood pressure (SBP) of 110 mm Hg and heart rate (HR) of 60 to 70 beats
per minute were recorded. Approximately four hours later, she developed bradycardia with HR of 35 to
40 per minute and SBP of 80mm Hg. Telemetry rhythm strips revealed A-V dissociation with junctional
escape rhythm at a rate of 32 per minute. The next doses of rIL2 were held and she was started on a
Dopamine infusion. HR and SBP improved within one hour and rhythm converted back to normal sinus
rhythm with HR in 60 to 65 per minute range. She remained in normal sinus rhythm and was successfully
weaned-off the Dopamine infusion over the next 12 hours. On receiving another dose of rIL2, similar
telemetry events were recorded which resolved with resumption of Dopamine infusion. Repeat
Echocardiogram was normal. All her laboratory values including electrolytes and cardiac enzymes were
within normal limits. Subsequently, all her future doses of rIL2 were put on hold and she was discharged
home after a day of uneventful observation.
Discussion: Most toxicities of rIL2 are related to capillary leak syndrome or lymphoid infiltration of
organs. rIL2 has also been likened to a Class 1 anti-arrhythmic agent due to its action on the sodium ion
channels in cardiac myocytes. To our knowledge, there has only been a single case report of IL2 induced
AV block/ brady-arrythmia. The postulated etiology could be transient dose-dependent lymphoid
infiltration of the AV node or the conduction system of the heart.
This case report demonstrates the repeated occurrence of AV dissociation with rIL2 therapy. In our case,
this was transient and reversible. This report underscores the need for close rhythm monitoring by
health care professionals and to be aware of this potential adverse event.
Chembrovich, MD
Ovarian Hyperstimulation Syndrom
First Author: Svetlana Chembrovich, MD Other Authors: Eugene Obah, MD, FACP, Greater Baltimore
Medical Center
Introduction: Ovarian hyperstimulation syndrome (OHSS) is a rare complication of controlled
hyperstimulation of the ovaries during IVF treatment. Although internists are less familiar with OHSS,
they could be first care providers to these patients occasionally.
Case Description: A 40 yo Caucasian female with infertility due to endometriosis with pelvic and
pleural implants came to our ED complaining of shortness of breath, mild abdominal pain and bloating.
She was undergoing her second cycle of IVF, day 2 post egg retrieval. In the ED she was found to be
dyspneic, tachycardic in 140s and hypotensive with BP of 60/40 mmHg. CXR demonstrated total rightsided hydrothorax. Abdominal ultrasound revealed small amount of free fluid in the pelvis and
significantly enlarged ovaries. Her labs demonstrated hemoconcentration and prerenal azotemia.
Her hemodynamics quickly improved with fluid resuscitation. Thoracentesis was performed with 4 L of
serosanguinous transudative fluid evacuated.CXR next morning demonstrated reaccumulation of the
fluid. Amount of ascites also increased. Over the next 4 days she underwent 3 thoracenteses for
symptomatic relief. She gradually developed anasarca and worsening of ascites. IR-guided pleural and
peritoneal catheters were placed for fluid drainage. Patient was maintained on IV fluids matching her
loses, Ibuprofen 1200mg a day, and Lovenox 40 mg daily. Albumin 25%-50g was given to maintain
oncotic pressure. Over period of 14 days, 8 L of fluid was drained from pleural and peritoneal cavities.
After withdrawal uterine bleeding developed on day 14, capillary leak gradually diminished; patient was
able to maintain intravascular volume and mobilize third-space fluid. She was discharged home on day
Discussion: In OHSS, multiple mature follicles release endothelial growth factor into peritoneal cavity
which gets absorbed into the circulation, resulting in massive capillary leakage and third-spacing.
Patients with severe OHSS present with massive pleural effusions, uni – or bilateral, ascites,
hypovolemia, hypotension, hemoconcentration, prerenal azotemia, and in severe cases with
hypovolemic shock, venous and arterial thromboses, respiratory failure, abdominal compartment
syndrome or ovarian torsion. The mainstay of treatment of OHSS is fluid resuscitation and symptomatic
relief with thoracentesis and paracentesis. Ibuprofen, a prostaglandin antagonist, can be given to
potentially reduce capillary leakage. Low molecular weight heparins should be given to prevent
thromboses. Albumin and hydroxyethyl starch can be used but are not superior to normal saline and
fluid drainage in reducing length of hospital stay or improving outcomes.
Conclusion: Early diagnosis of OHSS and prompt treatment can prevent potential complications and
provide symptomatic relief to these patients.
John, MD
Severe Pain Localized to 8 Inches in the Leg: A Case of Diabetic Muscle
First Author: George Kunnackal John, MD
Introduction: Diabetic muscle infarction or spontaneous ischemic necrosis of skeletal muscle is a rare
complication of uncontrolled diabetes usually seen in patients with other micro- and macro-vascular
complications such as retinopathy, neuropathy and nephropathy. We report a case of diabetic muscle
infarction of the vastus medialis muscle of the right thigh.
Case Presentation: A 55 year old African American lady with a 19 year history of Type –II diabetes with
multiple complications including proliferative retinopathy with retinal detachment and blindness in the
right eye, bilateral neuropathy of the lower limbs and nephropathy with end-stage renal disease
presented with 5 days of severe right thigh pain restricted to an 8 inch area of the antero-medial aspect
of the thigh associated with warmth and tenderness and inability to bear weight on the right leg. There
was no history of trauma or any muscle strain, no fever, chills or rigors, no history of travel or insect bite
and no swellings or rash associated with the onset of pain.
On examination her height was 5’ 7”, weight 208 lbs. The patient was noted to have swelling of the right
thigh with increased temperature and tenderness over the antero-medial aspect of the right thigh. Skin
overlying the area was intact. Bilateral pedal edema was present and peripheral pulses were palpable
bilaterally. Strength was 4/5 on the right side secondary to pain. Reflexes were normal bilaterally. The
rest of the physical exam was only remarkable for bilateral basal crepitations. Her WBC count was 8840
with 68% neutrophils. CMP was remarkable for a BUN of 85 and Creatinine of 8.1. Glucose was 172 with
HbA1C of 5.0. ESR was elevated at 140, Total CK of 344, Aldolase 7.8, INR 1.1 and PTT ratio 0.9. An ANA
screen was negative. Duplex scan of the right lower extremity was negative for DVT. MRI of the right
lower limb without contrast showed diffuse muscle edema in the anterior musculature of the right
thigh, most severe in the vastus medialis with extensive overlying subcutaneous and fascial edema in
the anterior and medial right thigh. The patient’s pain was controlled with long acting opiod analgesics
during hospital stay and was discharged home with crutches after a short sub-acute rehabilitation stay
for gentle weight bearing exercises.
Discussion: Spontaneous infarction of skeletal muscle is a rare complication and is a diagnosis of
exclusion. Some of the differentials to be considered include vascular, neoplastic, inflammatory and
neurological processes. High intensity in the involved muscle on T2 weighted MRI sequences and
subcutaneous edema and sub-fascial fluid is commonly seen. Muscle biopsy which is not routinely
recommended shows muscle necrosis, edema and occlusion of the arterioles and capillaries by fibrin.
The recommended treatment for this condition is rest and adequate analgesia with spontaneous
resolution usually seen in 6-8 weeks. The addition of anti-platelet agents such as aspirin has shown to
significantly decrease the recovery time.
Sangrampurkar, MBBS
Myeloid versus Lymphoid – a case of Biphenotypic Acute Leukemia
Rupali Sangrampurkar, MBBS, Nitin Sangrampurkar, MBBS, Harminder Sethi, MD, Sreedevi Kurulla, MD,
Lester Miles, MD.
INTRODUCTION: Leukemia or lymphoma is generally classified into two broad categories – myeloid or
lymphoid – based on the type of markers found on flow cytometry. This classification determines the
type of chemotherapy used. Rarely, leukemia may have features of both myeloid and lymphoid lineage
(Biphenotypic Acute Leukemia or BAL) which makes diagnosis and management quite challenging,
especially because of poor prognosis associated with this disease. Here we present a case of BAL with
certain unique features on flow cytometry.
CASE PRESENTATION: A 58 year old African American male with history of CHF, Atrial Fibrillation, Gout,
and Grave’s disease presented with 3-week history of exertional shortness of breath, diaphoresis, and
palpitations. On examination his vitals were normal with oxygen saturation of 94% on room air. He had
reduced breath sounds at right base, irregularly irregular heart rhythm, and dry exfoliated skin on
dorsum of both hands with black pigmentation on his lower back. His admission labs including ProBNP,
TSH, and free T4 were normal. EKG showed atrial fibrillation, chest X-Ray showed moderate right plural
effusion. The CT Angiogram of chest showed large anterior mediastinal mass (12x13x9 cm) encasing the
right pulmonary vein, mediastinal lymphadenopathy, and large right pleural effusion. Thoracentesis of
right side revealed cells consistent with acute leukemia of ambiguous lineage, with evidence of both Tcell and B-cell lineage differentiation. Outpatient mediastinoscopy with mediastinal LN biopsy was done
one week later. Flow cytometry analysis of the cells from mediastinal mass confirmed previous findings
of Biphenotypic leukemia, and target gene analysis revealed chromosome 10 trisomy and MLL gene
rearrangement. Patient was enrolled in CALGB study 8811 and has responded favorably to CALGB
DISCUSSION: Biphenotypic Acute Leukemia (BAL) accounts for 5% of all the leukemias. BAL has proven
to be very difficult to treat with many cases being resistant to induction chemotherapy and have a high
risk of relapse. 5-year survival of patients with BAL is 8%. Majority of patients receive treatment
according to morphology of the blasts. Most of the BAL cases discussed in literature so far have MLL
gene rearrangement, Philadelphia chromosome, chromosome 5 and 7 abnormalities. Our case had
chromosome 10 trisomy and MLL gene rearrangement and he responded well to induction
chemotherapy. The most important favorable prognostic features emerging for BAL are: age (<60 years),
absence of the Philadelphia chromosome, and achievement of complete remission. From the limited
data that is available, it is not clear if there is association between various types of cytological
abnormalities found and the overall prognosis, which might be worthwhile to investigate.
Paraneoplastic neurological syndrome due to occult fallopian tube carcinoma
First Author: Rohit K Jain, MD Second Author: Laxmi Iyer, MBBS Third Author: Rutika J Mehta, MBBS
Fourth Author: Kenneth Miller, MD
Introduction: Paraneoplastic cerebellar degeneration (PCD) is a rare neurological syndrome due to
remote effect of malignancy on nervous system. It is most commonly seen in small cell lung cancer,
Ovarian, Breast and Hodgkin Lymphoma. The syndrome is also linked to several antibodies such as anti
Yo, anti –Hu and anti-Tr. The link between breast, ovarian cancers and anti-Yo has been well studied.
Case Presentation: A 53 year old woman presented with impaired coordination, followed by dysarthria
and hoarseness of voice. In one month, the patient’s neurological symptoms had progressed to such an
extent that she had to use a walker. On examination she required 2-person assistance to stand upright
at the edge of the bed with prominent ataxia despite full strength in the lower extremities noted in the
seated position. A thorough neurological evaluation and work-up for malignancy including pelvic exam,
mammogram, CA-125, and CT scans were negative for malignancy . Bone marrow biopsy and flow
cytometry of the peripheral blood confirmed nodular lymphoid aggregates composed of CD20-positive
B-cells with aberrant co-expression of CD5 and CD23, consistent with a diagnosis of small lymphocytic
lymphoma/chronic lymphocytic leukemia. A PET CT scan demonstrated abnormal nodes in the
mediastinum and retroperitoneum. Further testing of serum for onco-neural antibodies revealed
presence of Anti Yo antibody. Patient obtained a complete remission with with Bendamustine and
Rituxan with resolution of the adenopathy on PET scan. However she continued to deteriorate
neurologically. Subsequently, with a rise in her CA-125 and the presence of a small amount of fluid in
the cul-de-sac she underwent TAH-BSO. She did not have evidence of gross malignancy at the time of
surgery, however further assessment of the specimen revealed a 1.5 cm mass in her left fallopian tube,
a high-grade serous carcinoma of the fallopian tube. Lymphatic invasion was absent. There was no also
clinical evidence of metastatic ovarian disease.
Discussion: This case highlights the importance of early detection of underlying malignancy in patients
with sub-acute neurological impairment including the possibility of very small primary tumors which are
clinically undetectable. Review of literature shows that only 6 cases have reported association of
paraneoplastic cerebellar degeneration with fallopian tube adenocarcinoma. This case report
emphasized that although rare, fallopian tube adenocarcinoma should also be considered as potential
cause of PCD. Although, no studies have noted any association between Fallopian Tube Adenocarcinoma
and PCD, it could be possible that it may be associated with disease and needs further research and
An Unusual case of bilateral Cryptococcal Choroiditis in an AIDS Patient with
Disseminated Cryptococcal Infection
First Author: Rutul J Dalal, MBBS,MD Second Author: Shalini Saith, MD Third Author: Faria Farhat, MD
Fourth author: Namrata Shah,MD
Introduction: We present a case of a 30 year old female with HIV who complained of blurry vision,
dizziness and productive cough for 2 weeks. She was found to have disseminated cryptococcal infection
and cryptococcal choroiditis without meningitis. Occular cryptococcal infection in the absence of
meningitis has been rarely reported.
Case Presentation: A 30 year old African-American female with a past medical history of HIV presented
with dizziness, blurry vision and cough . Blurriness of vision & dizziness were getting course over the last
week. She also had productive cough associated with high fevers.The patient was recently started on
highly active antiretroviral therapy (HAART).Her CD4 count at that time was 103 and HIV RNA PCR was
2,807,570 copies/ml.On admission, the patient was tachycardic & febrile at 100.9 degrees Fahrenheit.
Physical exam was unremarkable, except for left lower lobe crepitations. Laboratory data was
significant for a hemoglobin level of 7.5 g/dl and a creatinine level of 2.4 mg/dl.Chest X-ray was
significant for left lower lung consolidation.Neuroimaging was noted to be normal.On day 4, blood
cultures were noted to be positive for Cryptococcus neoformans. Serum Cryptococcal Antigen titer was
> 1:2048. Lumbar puncture revealed an opening pressure of 20 cm of water, and was otherwise
unremarkable.Ophthalmology evaluation was normal except for fundoscopy which revealed bilateral,
multiple, subretinal hypopigmented, yellowish lesions with indistinct borders, worse in the posterior
poles.Fluoroscein angiography done to exclude vasculitis was normal.Liposomal amphotericin B and
fluconazole for presumed disseminated cryptococcal infection were started. Bronchoscopy done for
hypoxia was unremarkable and all cultures were noted to be negative. She continued to improve and
repeat fundoscopic exam showed mild improvement.She was then discharged to a long term care
Cryptococcus neoformans is an encapsulated heterobasidiomycetous fungus,commonly seen in
immunocompromised patients.Portal of entry into human hosts is the lung with a special predilection of
infecting the central nervous system.Cryptococcus primarily affects the meninges with sequelae of
papilledema, optic atrophy, cranial nerve palsies. One of the least frequent complications of
cryptococcal meningitis is intraocular cryptococcosis.Most patients with CNS cryptococcosis present
with signs of meningism and have a positive CSF cryptococcal latex antigen test along with increased
opening pressures. All the above findings were negative in our case.Again, papilledema is the most
common finding of intraocular cryptococcosis.Primary involvement of the choroid alone is relatively rare
in HIV patients, and may indicate severe disseminated disease.Disseminated cryptococcosis involving
the lung had poorer outcomes. Our patient responded well to the treatment and within a week both the
respiratory and ocular symptoms showed marked improvement.
Discussion: In conclusion cryptococcal choroidits should be considered in HIV patients, even if they only
present with subtle signs of impaired vision without the typical signs of meningeal involvement. Vigilant
ophthalmic exam remains vital in making the right diagnosis.
Purulent pericardial tamponade due to Staphylococcus infection in a patient
with Human Immunodeficiency virus
First Author: Ruby Gupta, MD, Amandeep Singh, M.D., Pooja Mohan Rao,MD , Jose Bordon, M.D., Ph.D.,
AAHIVS Department of Internal Medicine, Providence Hospital, Washington,DC,USA
INTRODUCTION: Pericarditis due to Methicillin resistant Staphylococcus Aureus (MRSA) is a rare and a
life threatening phenomenon. We report a very rare case of purulent pericardial tamponade due to
MRSA after a skin and soft tissue infection.
CASE PRESENTATION: This is a 36 year old female who presented to the emergency department
complaining of gradually progressing shortness of breath and fever for the past five days, associated
with cough and non-bloody yellow colored sputum. Her past medical history was significant for HIV and
she was non- compliant with her anti-retroviral medications. She had bilateral gluteal abscess a month
ago which was incised and drained in the ER and patient sent back home on oral antibiotics.
On examination she had fever of 103 degrees F, was hypotensive, tachypneic and tachycardic. JVP was
marginally distended. Rest of the cardiac exam was normal. No pulsus paradoxus. She had two
carbuncles over the medial aspect of right thigh. She was lethargic but arousable on verbal stimulation.
No focal neurological deficits.
She was intubated as she failed trial of BIPAP and sent to ICU. WBC count was 14000 with left shift, CD4
count of 150 , abnormal cardiac enzymes. Chest X-ray showed mild globular heart, electrocardiogram
showed sinus tachycardia and nonspecific ST and T-wave abnormality. Clinical diagnosis of septic shock
was made. She was pancultured and started on broad spectrum intravenous (IV) antibiotics. Also
started on pressors. Echocardiogram showed impending pericardial tamponade with global hypokinesia
and LVEF of 35-45%.
Pericardiocentesis was done that revealed frank pus following which chest tube was placed which
drained 500ml of frank pus. Later the pericardial fluid, blood and urine culture was found positive for
MRSA. Over ten days of ICU care she was gradually weaned off from the vasopressors, ventilator and her
pericardial drain also decreased. On day fourteen, she was transferred out of ICU to Long Term Acute
Care facility (LTAC) to complete 4 weeks of IV antibiotics. Following incomplete treatment at LTAC, she
presented again with similar symptoms, requiring pericardiectomy. She was also found to have Iliac
bone MRSA osteomyelitis during this admission for which she was referred to Orthopedics.
Discussion: HIV infected patients are known to have 6 times increased risk of CA-MRSA compared to
non-HIV . The estimated incidence of cardiac tamponade secondary to MRSA pericarditis is
approximately 1-2% and mortality of between 40 and 75% . The rapidity with which the pericardial
effusion increased to pericardial tamponade, brings to our attention the need for use of frequent
bedside echocardiography, so that timely intervention can be initiated.
First Author: Hassan Ziud,MD Harbrinder Sandhu,MD Bahjat Makdisi,MD
To familiarize one with Adult onset Still Disease (ASD)
Introduction: Adult Still’s disease is an inflammatory disorder characterized by quotidian (daily) fevers,
arthritis, and an evanescent rash.
Case Presentation: This is a 76-year-old gentleman who presented with intermittent fever on a daily
basis for the last 4 months, with a maximum of 101.0 F. The fever used to last for several hours and it
was associated with Knees, shoulders,and ankles joints . Patient has been experiencing generalized
fatigue, weakness and morning stiffness for 15 minutes to on hour every day especially in his shoulders
and in both hands. The patient lost 17 pounds in 6 weeks. He denied any headache or throbbing pain in
the temporal areas, but he reported having on and off TMJ pain, facial pain associated with jaw
claudication, dysphagia and sore throat. His physical exam was significant for a fever of 100.7, diffuse
muscle tenderness, decreased elbow extension bilaterally with a maximum range of 150 degrees and
warm ankle joints bilaterally.
Work up:
WBC : 16.8, :476 ,ESR: 45, CRP:154 , AST: 362, ALT:244 , ALP:244, Ceruloplasmin: 40, Ferritin > 1350,
Aldolase 6.4, CPK:18, RF 109, Negative ANA ,CCP, and ANCA.
Head CT, ABD/CHEST/ABD CT: all are negative for infectious, inflammatory , or neoplastic lesions.
Gallium Scan:WNL , Liver biopsy: Nonspecific reactive changes, Bone marrow biopsy: negative for
malignancy or Myelodysplastic syndrome.
Temporal artery biopsies (bilaterally): Negative for temporal arteritis
Discussion: The Yamaguchi criteria require the presence of five features, with at least two being major
diagnostic criteria.This patient presented with three major criteria (fever, arthralgia, leukocytosis) and
two minor criteria (sore throat, and elevated transaminase). The high ferritin, negative ANA, and
negative CCP are very helpful to establish the diagnosis of ASD. Our patient did not have the typical
manifestations of rash. We excluded any infection, malignancy, or other rheumatic disorder known to
mimic ASD. Patient did not improve much on low dose of steroids but he had a better response with
higher doses. After discharge the patient did not continue to improve on high doses of Prednisone and
he continued to have an elevated CRP. An anti-TNF agent was then started after discharge, and his
symptoms significantly improved and a follow up CRP level was within normal limits.
Conclusion: Adult Still’s disease should be considered in the differential diagnosis of undifferentiated
fever in patients who are having arthralgia, myalgia, leukocytosis, elevated transaminase, and high
ferritin. Although ASD is a diagnosis of exclusion, it should always be considered in such cases.
Yamaguchi criteria and excluding other diseases that mimic ASD are very helpful to establish the
Hernandez Munoz
“The worse headache of my life”: Parasitemic in New England
First Author: Francisco J Hernandez Munoz Second Author: Jose Martagon-Villamil
Introduction: Babesiosis is a tick borne illness caused by a protozoa of the genus Babesia. In the United
States it is transmitted by the Ixodes scapularis tick which is the same vector for Anaplasmosis and
Lymes disease; therefore, co-infection with either must be ruled out if clinically appropriate.
Case Presentation: A 71-year-old man with paroxysmal supra ventricular tachycardia on diltiazem that
presented in January with the worst Headache of his life. Five days prior he reported to have general
malaise, body aches, fatigue and hypersomnolence. He went to his Primary Care Physician and was
diagnosed with “the flu”. After 48hours he developed a headache on the R side of his head, pounding in
quality and 6/10 in severity. At this point the Primary physician started doxycycline for a presumed sinus
infection. The next day his headache had progressed to “the worst headache of my life” and he decided
to go to the Emergency Room (ER).
On exam his vital sings were stable, he had no rash nor purpuric skin lesions, no focal neurological
deficits, no sings of meningismus, however he was holding on to his head in pain. He jogs 3-4 miles daily
and resides in Wilbraham, Massachusetts, no travel history outside of the United States. In the ER a
Head CT scan and a CXR were unremarkable. Lab work showed thrombocytopenia of 29K/mm3 with
hemoglobin of 12.7Gm/dL (baseline 15Gm/dL), sed rate of 35mm/hr and mild transaminitis On
admission further lab work showed high LDH with low haptoglobin and subsequently a peripheral blood
smear was found to have no schistyocytes but RBC inclusion bodies could be appreciated. Due to high
suspicion for Babesiosis patient was started on atovaquone and azythromycin and given low platelets he
was started on empiric treatment for Anaplasmosis. Subsequently thin prep “Malaria smear” was
positive for Babesia microti with parasitemia of 1-2%. Anaplasma titers were eventually negative and
doxycycline was stopped. Patient recovered with no complications after treatment.
Discussion: The range of symptoms for Babesiosis is extremely broad and nonspecific including fever,
general malaise, headaches, chills, sweats and weakness, all the way to the development of ARDS or DIC
leading to death. Human babesiosis is a rare but debilitating and potentially fatal illness, especially in the
elderly [2]. Because of this nonspecific spectrum of symptoms associated with Babesiosis a high degree
of suspicion in endemic areas is needed and in the elderly population early treatment may prevent
progression to severe disease and death. Beause Thrombocytopenia is more commonly described in
Anaplasmosis and both conditions and are transmitted through the same tick, empiric treatment for
anaplasma was started.
1.Vannier E, et al. Human babesiosis. Infect Dis Clin North Am. 2008;22(3):469.
3. White DJ , et al Human babesiosis in New York State: Review of 139 hospitalized cases and analysis of
prognostic factors. Arch Intern Med. 1998;158(19):2149.
Somalaraju, MD
Vasospasm from 5-fluorouracil - A Kounis Syndrome ?
First Author: Sandeep Somalaraju, MD, Dahlia Banerji, MD, Alireza Hosseinnezhad, MD, Ajay
Ramanakumar, MD, Allen Filiberti, MD
Introduction: Cardiotoxicity from 5-FU is well known though rare. The spectrum can range from angina
to cardiogenic shock, a mechanism thought to be from vasospasm. With a half-life of 10 minutes,
complications are known to arise mostly during infusion. Late complications represent a diagnostic
challenge, either by vasospasm or an allergic reaction -Kounis syndrome.
Case Presentation: A 53-year-old woman was started on concomitant radiation and chemotherapy for
recently diagnosed stage 2 rectal adenocarcinoma. She has a history of migraines controlled well with
Topiramate and no known cardiovascular disease. There were no prior allergies reported. She tolerated
the first cycle of 5-FU infusion with intermittent nausea and vomiting and non-radiating waxing and
waning central chest pressure a few hours after completion of therapy. These symptoms subsided
following the first cycle of treatment 3 weeks ago. 14 hours after the first dose of her second cycle, she
awoke with flushing of her face in addition to her previously described complaints. These events would
occur episodically with brief periods of normalcy. With progression she took 162 mg of aspirin and 12
hours into the onset of her symptoms she was admitted to our hospital.
An initial EKG demonstrated sinus tachycardia with mildly concave ST segment elevations and some Twave inversions in the infero-lateral leads. Laboratory findings revealed a Troponin T of 0.133, CK 117
U/L, CK-MB 3.7 %, eosinophil count of 4% and normal IgE levels. Sublingual nitroglycerin resulted in
complete symptom resolution. She had received aspirin, clopidogrel and was initiated on a heparin drip.
A subsequent EKG revealed sinus rhythm with minor T-wave inversions in I, aVL and VI. Cardiac
catheterization demonstrated angiographically normal coronaries. Based on the LV gram, an EF of 55%
and moderate infero-basal hypokinesis was reported. The patient remained asymptomatic with
normalization of her cardiac markers in the following examination. With a presumption of 5-FU induced
vasospasm, calcium channel antagonist was prescribed with nitrates as needed and she was advised to
refrain from further 5-FU.
DISCUSSION: Cardiovascular hypersensitivity with 5-FU has been rarely noted on literature review
several hours post therapy. Its half-life is about 10 minutes. A proposed mechanism caused by
inflammatory mediators was described by Dr. Kounis in 1991 as the syndrome of “allergic angina” with
the coincidental occurrence of chest pain and allergic reactions. We suspected Type-1 Kounis syndrome
variant in our case as her coronaries were clean. She was advised adding antihistamines as this
syndrome has been successfully treated by them.
Varadarajan, MBBS
Can Genital lesions cause chest pain?
First Author: Indumathy Varadarajan, MBBS Other Authors : Eunice Chuang MD , Alexandra Chabrerie
MD, Robert Colgrove MD
INTRODUCTION: Genital herpes caused by HSV 2 is a common sexually transmitted infection.
Extragenital complications include aseptic meningitis, sacral autonomic nervous system dysfunction and
development of extragenital lesions .In a study of 624 patients incidence of HSV pericarditis was less
than 1 % .
CASE PRESENTATION: 30 yr woman with past medical history of asthma ,uterine fibroids , s/p
cholecystectomy presented to the ED with acute onset of chest discomfort . The chest discomfort was
substernal, plueritic in nature, relieved by sitting and leaning forward and exacerbated by lying down .
She also had some dyspnea on exertion but no orthopnea. 3 days prior to this presentation she was
seen at her PCP ‘s office for vesicular lesions on her labia and was started on Acyclovir for HSV 2 .Her
medications include HCTZ for chronic leg edema , Acyclovir , OCP and an Albuterol inhaler .She had no
gallops , rubs or murmurs on examination. Shallow well rounded painful lesions in the labia consistent
with herpes were noted. EKG revealed PR segment depression in II and III. Labs were significant for a
troponin leak which peaked at 1.43 and an elevated HSV IgM of 0.16ul/ml. Cultures obtained from the
genital lesion grew HSV2 . Echocardiogram revealed an ejection fraction of 55-60 % without any
pericardial effusion, or wall motion abnormalities. She was diagnosed with myopericariditis from a HSV
2 viral infection and was discharged with Ibuprofen and acyclovir for total 15 days.
DISCUSSION: Viral infections appear to be the commonest causes of myopericarditis in developed
countries. Frequent viruses encountered include Coxsackieviruses, adenoviruses, cytomegaloviruses,
echovirus and influenza virus. However very few cases of HSV 2 pericarditis have been reported, even
those seem to occur in immunocompromised hosts .Our patient was HIV negative by both the Elisa and
Western blot method. She had an adequate CD 4 count and no other evidence of immunodeficiency.
Cardiotropic viruses can cause a direct cytolytic or cytotoxic damage to the myocardium. This may
provoke release of intracellular proteins and trigger immune responses that may be responsible for
further damage in the presence of a predisposing genetic background. Classical diagnostic criteria for
acute pericarditis include typical pericardial chest pain, frictional rub, widespread ST-segment elevation
or PR depressions not previously reported, and pericardial effusion. Our patient had a classical history,
EKG changes and a troponin leak . Treatment of viral pericarditis is directed to resolve symptoms,
prevent complications, and eradicate the virus, hence our decision to treat her with NSAIDS and
Mahatanan, MD
Human Babesiosis: A case series from suburban Massachusetts
First Author: Rattanaporn Mahatanan, MD Second author: Rungwasee Rattanavich, MD Third author:
Nikolaos Mavrogiorgos, MD
Introduction: Human babesiosis is caused by Babesia microti and is a tick borne disease transmitted by
the Ixodes scapularis tick. Coinfection with other tick borne diseases, such as Lyme disease and
Anaplasmosis, occasionally occurs. Babesiosis is endemic mainly in parts of the Northeast and upper
Midwest; and its incidence usually peaks during the warm months. Clinical manifestation can range in
severity from asymptomatic to life threatening. The number of cases has been increasing recently. We
herein report a case series of babesiosis, diagnosed in 2012 at a community hospital in Massachusetts.
Case series: In 2012, a total of 10 patients were diagnosed with babesiosis at Metrowest Medical Center
in Framingham, which represents a significant increase compared to prior years. Mean age was 62 years
old (range 40-82 years old). Seven patients were male. Almost all cases presented between July and
August. Two cases required ICU admission. Half of the patients had no past medical history and one
patient was asplenic. Only one patient recalled a tick bite. The most common presenting symptoms
were fever and generalized weakness. Most patients had anemia. Thrombocytopenia was found in nine
patients. Diagnosis was made by peripheral blood smear in nine patients, while in one patient diagnosis
was made by PCR. Co-infection with Lyme disease was detected in three patients and one patient had
Anaplasmosis. The clinical course ranged from mild febrile illness to severe sepsis. One patient
developed ARDS. Another patient had splenic infarcts. Most patients were treated with atovaquone and
azithromycin. One patient did not respond to this regimen but improved on quinine plus clindamycin.
There were no deaths.
Discussion: We saw a significant increase in the number of babesiosis cases in 2012 compared to prior
years. This is probably due to warmer weather in the recent years, resulting in expansion of the tick
population, and seems to follow the steps of the Lyme disease epidemic seen in the recent years in the
area. Increased physician awareness might be contributing to the increased number of cases as well.
Clinical features can vary, but hemolytic anemia and thrombocytopenia should raise the suspicion for
babesiosis, particularly during the summer months. The diagnosis can be made promptly by peripheral
blood smear, however distinguishing between babesiosis and malaria is still problematic and physicians
should use clinical judgment and consider relevant travel history. PCR is a highly sensitive and specific
test, which can be used to confirm the diagnosis. Patients commonly improve with the combination of
azithromycin and atovaquone, but there have been reports of clinical failure, as in one of our patients.
Gnanapandithan, MD
Gastro-Esophageal Reflux and Pulmonary Fibrosis: A Long Term Relationship
First Author: Karthik Gnanapandithan, MD Ramprakash Devadoss, MD (Associate) Joel Popkin, MD
(FACP), Kevin Martin, MD Departments of Medicine, St. Vincent Hospital and the Reliant Medical Group,
Worcester, MA
Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive disease with a steady downhill course,
despite the various treatment strategies. Gastro-esophageal reflux (GER) is known to occur in a high
proportion of patients with IPF, and gastic acid has been shown to promote fibrogenesis in animal
models. We describe a patient with IPF whose disease process was drastically altered by GER.
Case Presentation: A 56 year old female was diagnosed with achalasia about 3 years prior to the current
presentation, for which she was treated with a proton pump inhibitor (PPI) and serial endoscopic
injections of Botox in the lower esophageal sphincter with partial relief of symptoms. Thereafter, she
developed slowly progressive shortness of breath and cough. Imaging revealed interstitial thickening,
and pulmonary function tests (PFTs) were suggestive of a restrictive pattern. Thoracoscopic lung biopsy
showed a usual interstitial pneumonia, consistent with IPF. She was managed conservatively with
steroids and PPIs. Over the next two years she was doing well symptomatically, but PFTs showed a very
gradual decline in lung volumes and diffusion capacity. Later she had recurrent aspiration pneumonitis
and progressive reflux symptoms, for which she underwent laparoscopic Heller’s myotomy (LHM) with
Nissen’s fundoplication. Following that, she decompensated with severe shortness of breath and
hypoxia, requiring continuous nasal oxygen. Barium studies revealed dilatation at the region of
fundoplication with reflux of gastric contents and normal gastric emptying. Repeat imaging in four
weeks revealed severe honey combing with superimposed pneumonitis.
Discussion: It is still unclear if a causal relationship exists between GER and IPF, but studies have shown
an increased prevalence of acid reflux in patients with IPF and its association with disease progression. A
few retrospective studies have shown that aggressive anti-reflux measures can stabilize pulmonary
functions in IPF and reduce the number of exacerbations. Since our patient had an anatomical
abnormality in the form of achalasia that predisposed to acid reflux, she underwent surgical treatment
in the form of LHM with fundoplication. Another similar case in a case series of IPF has been reported
who had laparoscopic repair of hiatal hernia with fundoplication and had worsening of symptoms and
decline in PFTs on follow up. In conclusion, this case reinforces that reflux can significantly worsen
clinical outcome in IPF. More studies need to be conducted to establish the significance of acid
suppression in patients with IPF and formulate the optimal anti-reflux strategy. Data on surgical
treatment of reflux in these patients is still minimal.
Arunachalam, MBBS
Unusual presentation of Cardiobacterium hominis endocarditis
First Author: Karuppiah Arunachalam, MBBS* Co-Authors-Indumathy Varadarajan MBBS*, Eunice
Chuang MD*, Barbara Blair MD* * Mount Auburn Hospital, Harvard Medical School
Introduction: Historically atrial fibrillation has been found to be present in some series in up to 26% of
those with subacute bacterial endocarditis most often involving the mitral valve. Cardiobacterium
hominis belongs to HACEK group [Hemophilus, Actinobacillus, Cardiobacterium, Eikenella and Kingella]
of organisms which are implicated in 3% of cases of subacute bacterial endocarditis. We present a case
of rapid atrial fibrillation ultimately attributed to bioprosthetic valve endocarditis due to C. hominis
highlighting the necessity to exclude infection when evaluating the patient with a recurrence of
supraventricular tachycardia.
Case presentation : An 80 year old male with past medical history of atrial fibrillation on Coumadin,
Tachy Brady syndrome with pacemaker, status post mitral valve prosthesis and Alzheimer’s dementia,
presented with 3 weeks of bright red blood per rectum and weakness complaining of palpitations and
profuse sweating for 2 days. In the Emergency department he was found to be tachycardic, hypotensive
with an EKG demonstrating atrial fibrillation with a rapid ventricular response. In addition to anemia and
a supratherapeutic INR, further initial laboratory evaluation revealed one of two blood culture bottles
growing gram negative bacilli. The patient was empirically treated with ceftriaxone and a
transesophageal echocardiogram showed 1cm mobile vegetation on the atrial surface of the
bioprosthetic mitral valve with minimal regurgitation. The blood culture isolate was identified as
Cardiobacterium hominis. Subsequently, ceftriaxone was administered for 6 weeks through PICC line
and no surgical intervention was undertaken.
Discussion: Occurrence of atrial fibrillation in subacute bacterial endocarditis is more common in the
elderly (average age of 60 yr) and predicts higher mortality. Cardiobacterium hominis endocarditis is
known for a spectrum of unusual clinical presentations, non-specific symptoms and protracted clinical
course. This patient presented with 2 month of constitutional symptoms, sudden onset of
supraventricular tachycardia and no peripheral signs of infective endocarditis. Other unusual
presentations of C. hominis endocarditis include septic arthritis, mycotic aneurysm, congestive heart
failure, thrombocytopenia and acute coronary syndrome. Most often this disease has a chronic clinical
course and requires prolonged antibiotic therapy. C. hominis endocarditis has been reported to occur
after dental procedures, upper GI endoscopy and colonoscopy. This case illustrates the need for high
clinical suspicion to detect less common presentations of C .hominis endocarditis to prevent significant
1. A J Eisner. Atrial fibrillation in bacterial endocarditis. Br Heart J. 1971 September; 33(5): 739–741.
Das M, Badley AD, Cockerill FR, Steckelberg JM, Wilson WR. Infective endocarditis caused by HACEK microorganisms. Annu Rev Med. 1997; 48:
Apisarnthanarak A, Johnson RM, Braverman AC, Dunne WM, Little JR. Cardiobacterium hominis bioprosthetic mitral valve endocarditis
presenting as septic arthritis. Diagn Microbiol Infect Dis. 2002 Jan; 42(1):79-81.
Lin BH, Vieco PT. Intracranial mycotic aneurysm in a patient with endocarditis caused by Cardiobacterium hominis. Can Assoc Radiol J. 1995
Feb; 46(1):40-2.
Shivaprakasha S, Radhakrishnan K, Kamath P, Karim P. Late prosthetic valve endocarditis due to Cardiobacterium hominis, an unusual
complication. Indian J Med Microbiol. 2007 Jan; 25(1):64-6.
Jod-Basedow phenomenon in patient with Graves’s disease visiting from an
iodine deficient region
First Author: Aaron C Roberts, MD Other Authors: Lorenzo Zaffiri, MD, Mark E Loehrke, MD, Joseph
D’ambrosio, MD
Introduction: Jod-Basedow phenomenon is described as thyrotoxic event caused by exposure to
increased amounts of iodine. It has historically been documented in regions deficient in iodine.
However, this phenomenon has been increasingly reported as a consequence of administration of
iodine-containing contrast for imaging studies. We present an interesting case of recurrent atrial flutter
and pulmonary edema secondary to Jod-Basedow phenomenon induced by increased iodine supply in a
patient with Graves’s disease.
Case Presentation: The patient is 48-year-old female who presented with sudden onset of tachycardia,
chest pain and shortness of breath. She was visiting a family member in the United States and planning
on returning to Tanzania the next day. She was previously treated with carbimazole for her Graves’s
disease for six months with improvement of her symptoms. On admission, physical exam was significant
for a large goiter, tachycardia with an irregular rhythm bibasilar crackles on lung auscultation and trace
pedal edema. EKG demonstrated atrial flutter. CT chest with iodine contrast showed enlarged
pulmonary arteries, cardiomegaly and peribronchial cuffing suggestive of heart failure. Her TSH was 0.01
U/mL and free T4 2,5 ng/mL, the rest of the laboratories exam were within normal limits. She was
admitted to the intensive care unit (ICU) for non-invasive positive pressure ventilation. Treatment with
propylthiouracil 200 mg three times a day and propanol was started as well as furosemide intravenously
with rapid clinical improvement. However, she refused to undergo cardioversion to return home to
Tanzania. Within 24 hours of being discharged, patient was admitted again with signs and symptoms of
pulmonary edema. EKG demonstrated again atrial flutter. Her respiratory status quickly deteriorated
requiring emergent intubation for acute respiratory failure. During this admission, hydrocortisone 50 mg
every 12 hours was added to the previous regimen. Cardiac catheterization showed a markedly elevated
left ventricular diastolic pressure of 35 mmHg, but no evidence of coronary artery disease. An
echocardiogram showed an ejection fraction of 35-40%. The patient was extubated after three days and
discharged in good condition.
Discussion: Thyrotoxicosis is due to an independent production of thyroid hormones by autonomous
areas within the thyroid gland. The increased iodine supply induces the production of thyroid hormones
independently by normal regulatory mechanism. Upon further review, several factors prompted the
thyrotoxic manifestations in our patient. Firstly, she was visiting from an endemic iodine deficient region
of Africa. Moreover, the combination of an iodine-rich diet and a large amount of iodine-containing
contrast contributed to the Jod-Basedow phenomenon and tachycardia-induced cardiomyopathy.
In conclusion, this case highlights the risk of inducing thyrotoxicosis in patient visiting from an endemic
iodine deficient region.
An Unusual Presentation of Stenotrophomonas maltophilia
First Author: Faris El-Khider, MBBS - Wayne State University Detroit, MI Athar Haq - Wayne State
University Detroit, MI Ahmed Ahmed Rogue Regional Medical Center Medford, OR Rohit Gupta - Wayne
State University Detroit, MI
IntroductionStenotrophomonas maltophilia is a common cause of nosocomial infection in
immunocompromised patients. We present a rare case which is amongst the first reported ones with a
community-acquired S. maltophilia osteomyelitis in an IV drug user.
Case PresentationOur patient is a 58 year-old male IV heroin user presents to the VA Medical Center in
Detroit, MI with lower left extremity pain for three weeks. Vital signs were unremarkable. Examination
of the back revealed point tenderness in the lumbar area and paraspinal muscle
spasm. Neurological examination was positive for left lower extremity weakness. C-reactive protein and
sedimentation rate were elevated. Prior to initiation of antibiotics, magnetic resonance imaging
revealed osteomyelitis and a paraspinal abscess at L5 - S1. Open biopsy and abscess drainage was done.
The patient was empirically started on vancomycin and piperacillin/tazobactam. Tissue cultures grew
multi-drug resitant S. maltophilia susceptible to trimethoprim / sulphamethoxazole and levofloxacin.
The patient was discharged with 6 months of oral trimethoprim-sulfamethoxazole 640/3200 every 8
hours. The patient was scheduled to follow with infectious disease clinic 2-3 weeks after discharge.
Length of treatment was to be determined at his follow-up appointment.
DiscussionStenotrophomonas maltophilia is a nonfermenting gram-negative bacillus. It is a common
cause of nosocomial infections in immunocompromised patients, but it is also reported as a cause of
osteomyelitis following farm and factory machine injuries (Harkness et al 1998 and Aggar et al 1986). In
intravenous drug users, it is also known to cause endocarditis. This case is unusaul because the patient
IV drug user who is not immunocompromised, nor was the organism nosocomially acquired. Despite
there being several reported cases of osteomyelitis caused by S. maltophilia, only one case was
followed and was successfully treated.
Antimicrobial therapy is usually a challenge as the organism is notorious for resistance. S. maltophilia is
mostly resistant to ß-lactams, and to a lesser extent to quinolones. With few exceptions, most studies
have found trimethoprim-sulfamethoxazole to be active against most strains.
Severe Hypereosinophilia Secondary to a Dialyzer Reaction
First Author: Michael Burton, MD Samira Ahsan, MD Muhammad Ahsan, MD Rajendra Manam, MD
Introduction: Dialyzer reactions are all maladies related to the interaction between the hemodialysis
membrane and blood constituents. There are two types of dialyzer reactions, type A and type B. Type A
dialyzer reactions are generally quicker in onset and more severe than type B, and luckily less common.
Case Description: A 67-year-old male who has a history significant for end-stage renal disease,
hypertension, and insulin-dependant diabetes mellitus presents to the hospital via EMS after developing
dizziness, chills, diaphoresis, and dyspnea immediately after the initiation of hemodialysis. He has been
dialysis dependant for the last three years and recently changed dialysis centers. Initial cardiac workup
was unremarkable. On a complete blood count, he was noted to have a leukocytosis of 20.5 K/mcL with
an eosinophilia of 39.50 percent on differential. On repeat labs, he was noted to have in increase in
leukocytosis to 38.2K/mcL with an eosinophilia of greater than 80 percent on manual differential.
Infectious diseases were consulted and subsequently infectious etiologies were ruled out. Hematology
and oncology were thus consulted and the patient underwent a bone marrow biopsy which only
demonstrated eosinophilia and was otherwise negative for malignancy. An IgE level was noted to be on
the lower end of normal and an autoimmune workup was unremarkable. The patient was noted to be in
the reuse program with a peroxyacetic acid and hydrogen peroxide mixture as the sterilizing agent.
After his dialysis was changed back to a non-reuse dialyzer; he had resolution of his symptoms and his
laboratory anomalies abated.
Discussion: Type A dialyzer reactions are noted to occur in four of every 100,000 dialysis treatments.
Symptoms occur immediately once the blood from the dialysis circuit returns to the patient. Symptoms
range from mild to severe. More severe reactions lead to dyspnea, hypotension, a sense of impending
doom, and even cardiac arrest. Most notably, ethylene oxide was a known cause of these reactions
when used to sterilize the dialyzer with a proposed mechanism of increased kinin generation. However,
rarely are type A reactions seen with reused dialyzers. There has been no current association found with
the disinfectant, reprocessing method, or type of dialysate used. However, in one study there was an
increased risk when washing the blood component of the hemodialyzer with either bleach or hydrogen
peroxide. Treatment is supportive and depends on the severity of symptoms. When suspected, the
dialysis treatment should be stopped immediately without returning the blood to the patient.
A rare case of fulminant hepatic failure in the setting of radiographically silent
metastatic liver disease
First Author: Syeda Hina Batool, MD Other authors: Raza Abbas, MD Iuliana Niculescu, MD
Introduction: Diffuse metastatic liver disease presenting as fulminant hepatic failure from an occult
primary is a rare phenomenon. We illustrate a unique case of new onset liver failure subsequently
proven to be secondary to an occult metastatic invasive ductal breast cancer in a patient with previously
cured invasive lobular breast carcinoma. Radiographically occult, multiple primary cancers of the same
site presenting as acute liver failure have not been reported in literature before.
Case Presentation: A 67 year old previously healthy female was sent from her primary care physician’s
office with acute onset concurrent liver and renal failure. For the past one month, patient had been
struggling with progressive weakness, fatigue and anorexia. Twenty years ago, the patient underwent
mastectomy followed by chemotherapy and radiation for a localized invasive lobular carcinoma. She
went on to have recurrence in the contralateral breast nine years later, treated similarly. Examination on
this admission revealed a somnolent female with jaundice and diffuse edema. No stigmata of chronic
liver disease were identified other than ascities. Laboratory studies aided the diagnosis of fulminant
hepatic failure with elevated liver enzymes, bilirubin, ammonia, INR and decreased level of albumin.
Paracentesis revealed a serum-ascites albumin gradient (SAAG) of greater than 1.1. Extensive workup
ensued to rule out all possible etiologies of acute and chronic liver failure, including ultrasound and CT
scans of chest, abdomen and pelvis, which essentially revealed a normal appearing liver. Hepatic
venogram indicated marked portal hypertension with no filling defects. Biopsy showed diffuse
infiltration of liver parenchyma by metastatic ductal carcinoma of the breast. Comparison with prior
tissue specimens revealed different histopathology of current disease, confirming the diagnosis of a new
primary breast malignancy. Patient was started on Letrozole and Faslodex. However, she died of
disseminated intravascular coagulation (DIC) within one week of discharge from the hospital.
Discussion: There are several unique aspects of this case. First off, is the masked, yet devastating
presentation of fulminant liver failure for an occult malignancy, which is quite rare, the incidence
reported being less than 0.44% in literature. Secondly, the conflicting results of liver biopsy in the setting
of completely normal radiographic studies, negates relying solely on imaging studies for diagnosing
metastatic disease. Third, the etiology of ALF was unraveled only on autopsy in almost all cases in
literature. However, we were able to make an early diagnosis due to an aggressive approach, which is
what we recommend. Last is the surprising discovery of a new primary breast malignancy in a patient
with previously cured breast cancer. Therefore we propose the inclusion of metastatic infiltrative
disease as a differential for idiopathic fulminant hepatic failure in an otherwise healthy individual.
The Importance of Early Recognition of a Novel Monoclonal Antibody Adverse
First Author: Maha Alhusseini, MD Garg Deepak, MD Pranatharth Chandrasekar, MD Marwan Alhajeili,
The presentation of fever, tachycardia, and encephalopathy makes an infectious process high on the
differential. However, in a patient with metastatic cancer on monoclonal antibody therapy, the clinician
must keep a wide differential and be aware of the adverse events these drugs are associated with. We
present a case of a 55 year old female with metastatic melanoma to the pelvis on ipilimumab, who
presented with headaches, encephalopathy, fever, and tachycardia after her third cycle of ipilimumab.
On physical exam, she was febrile, tachycardic, alert but not oriented, meningeal signs were negative,
and there were no focal deficits. CBC, electrolytes, and renal function were normal. The patient was
started on empiric antibiotic therapy pending infectious workup. CXR, blood and urine cultures, CT
head, and lumbar puncture were all negative. Her vital signs and encephalopathy worsened, and the
patient required admission to the intensive care unit. MRI of the brain revealed a serious adverse event
of ipilimumab: lymphocytic hypophysitis which is an autoimmune destruction of the pituitary gland
shown on this patient’s MRI as pituitary enlargement. This was confirmed with hormonal workup which
revealed depressed ACTH, TSH, LH, and FSH. She was started immediately on corticosteroids. Her
encephalopathy and vital signs dramatically improved, and she was back to her baseline in less than 24
Ipilimumab, approved by the FDA in March 2011, is an IgG1 monoclonal antibody against cytotoxic Tlymphocyte–associated antigen 4 (CTLA-4), a negative regulator of T cells, and thereby the drug induces
unrestrained T-cell activation and anti-tumor response. In patients with advanced melanoma,
ipilimumab produced considerable disease control rates, and for the first time, an improvement in
overall survival outcomes making them attractive agents to be used in this setting. This class of drugs
produces a wide array of adverse events including rashes, colitis, hypophysitis, hepatitis, pancreatitis,
iridocyclitis, lymphadenopathy, neuropathies, and nephritis. Almost all patients who develop immune
related adverse events experience clinical resolution of symptoms following withdrawal of the drug and
starting steroids. Hypopituitarism is the only potentially irreversible event. Vigilance of the adverse
events of these more recently used drugs is important as they can be fatal if left untreated but easily
treatable if clinically suspected and diagnosed.
Kahlon, MD,MBBS
Thrombocytopenia-Did you look at the slide?
First Author: Roopkiranjot K Kahlon, MD,MBBS Second Author: Rana Mansour D.O Third Author: Carter
Bishop M.D
Introduction: Platelet satellitism is an important cause of pseudo-thrombocytopenia. Platelet satellitism
was first reported in the early 1960's. Platelet rosetting or satellitism is described as an uncommon
finding characterized by formation of platelet rosettes around polymorphonuclear (PMN) leucocytes,
which are seen in Giemsa-stained peripheral blood smears prepared from EDTA- anticoagulated blood
samples, but not seen when others anticoagulants such as heparin, acid- citrate dextrose, or citrate, are
Case Description: 66 year old man with past medical history of CAD s/p CABG in 2004 and multiple
stents in the past, hypertension, pulmonary hypertension, and COPD. He was admitted left sided chest
pain, progressive shortness of breath and chronic left leg swelling under cardiology service. Patient
reported history of occasional bruising for the past 1 year. He said bruises occur with injury, he did have
2 small about 1-2 cm in diameter on left inner arm near axilla. His vital signs were normal and physical
exam was significant for 2cm small bruise in healing phase on left inner arm, and left leg chronic non
pitting edema secondary to the vein grafting done for CABG. Patients cardiac enzymes were normal with
no new EKG findings, last stress test was done 6 months ago was normal. Doppler of leg was done,
which did not show any clots. Day 3 of admission patient’s platelet count started dropping from 136000
to 51000/cumm (normal range 150,000-450,000 /cumm). Patient had been on aspirin and clopidogrel
for past 5 years with baseline platelet counts of 98000/cumm. His other cell lines were within normal
limits. Upon review of his blood smear platelet satellitism was seen, platelet clumping around
polymorphonuclear neutrophils. The slide was remade using citrate, which did not show any platelet
satellitism and normal platelet count. No treatment was further required.
Discussion: Platelet satellitism and platelet clumping can cause pseudo-thrombocytopenia. The
mechanism of this platelet adhesion to PMN is not clearly understood, but there is evidence that
autoantibodies directed to the glycoprotein IIb/IIIa complex on the platelet membrane, as well against
the neutrophil Fc receptor, are involved. There is a possibility that the epitopes for those antibodies are
usually hidden in leukocyte and platelet membranes and the membrane changes are induced by EDTA
exposure;that is why satellitism is observed exclusively with EDTA. Phagocytosis of entire platelets has
also been reported occasionally by the polymorphonuclear cells.The results of both in vivo and in vitro
platelet-function tests are normal.As such platelet satellitism has not been directly associated with any
systemic disorder. If platelet satellitism is observed on the peripheral smear, the sample could be
recollected using sodium citrate as the anticoagulant, no treatment is required for this condition.
Sadiq, MBBS
First Author: Muhammad Salman Sadiq, MD Harsha Ramchandani, MD James Kruer, MD
INTRODUCTION: Cannabis is the third most commonly used drug in United States, just second to
tobacco and alcohol use. Studies have demonstrated benefits from cannabis in neuropathic pain, cancer
pain, appetite stimulation in HIV, and suppression of nausea and vomiting during chemotherapy. In
recent studies, paradoxical emetic effects have been recognized in patients with chronic cannabis use.
First case report of CHS was published in 2004 involving 9 patients in Australia. Hereby, our case
illustrates an uncommon but severe side effect of cannabis use.
Case Presentation: An 18-year-old Caucasian female with PMH significant for depression, anxiety, panic
attacks and hypothyroidism, presented to the hospital with two days history of nausea, vomiting and
abdominal pain. She denied any diarrhea or fever. Denied eating anything outside recently. She felt
better every time after taking hot showers. She had similar episodes in the past, which got better by
taking hot showers in 3-4 days. Social history was significant for smoking marijuana daily since age of 13.
Patient’s vital signs in ER were stable. Urine was positive for benzodiazepines and cannabinoids.
Imaging studies of abdomen were unremarkable. She was given multiple antiemetics and IV fluids.
Patient continued to be symptomatic and keep asking for hot showers. She was allowed to use hot
showers to help her feel better. Symptoms lasted for 3 days after the last marijuana use before they
were completely resolved.
Discussion: According to NIH, 16.7 million Americans over the age of 12 yrs use marijuana. Side effects
of marijuana include nausea, vomiting (CHS), decreased short-term memory, dry mouth, red eyes,
impaired perception and motor skills. More serious side effects include panic, paranoia, or acute
psychosis. Cannabinoids exert their effects via two primary receptors, CB1 and CB2. CB1 receptor is
found mainly in the CNS and is associated with nociception and dysregulation of hypothalamic-pituitary
axis. Over stimulation of CB1 causes an increase in release of corticotrophin releasing factor (CRF) which
may be contributory for cyclical vomiting. CB1 receptors may also play an important role in compulsive
bathing in CHS patients by causing an increase in GABA release. Increased GABA activity in turn leads to
hypothermia. As a compensatory mechanism, patients tend to take long, hot showers.
The diagnosis of CHS should be a diagnosis of exclusion in the presence of cannabis use. Management
requires adequate hydration. Though, antiemetic therapy can be used, it does not seem to provide
much benefit. Patients tend to respond well to hot showers. On average, patients require supportive
care for 24-72 hours. Finally, patients should also be advised to avoid using cannabis.
Displacement of Impella post chest compressions – Necessity of vigilance
First Author: Sourabh Aggarwal, MBBS Ravikanth Papani, MBBS Sangeeth Dubbireddi, MBBS Susan
Bannon, MD
Introduction: Circulatory assist devices are increasingly being used for a wide range of clinical
conditions. The Impella® 2.5 device (Abiomed), a left ventricular assist device, is a catheter pump
implanted via the transcutaneous femoral route across the aortic valve into the left ventricle. The pump
draws the blood out of left ventricle and ejects it into the ascending aorta resulting in active drainage.
We report an interesting and important clinical scenario associated with the use of Impella.
Case: A 49-year-old man presented with complaints of severe retrosternal chest discomfort. His EKG and
rising troponins indicated myocardial infarction and he was taken emergently to the catheterization lab.
Blockage was found in his left anterior descending (LAD) and left circumflex arteries (LCX). Thrombolysis
and angioplasty were performed. Post-procedure he developed flash pulmonary edema. He was
intubated and admitted to the ICU. Soon thereafter, he had new ST segment elevations with rising
troponin. He was again taken to the cath lab. The arteries were patent, but LV ejection fraction had
dropped to 20%. An Impella device was placed and he returned to the ICU. Few hours later he had
pulseless ventricular tachycardia with return of spontaneous circulation after chest compressions. Chest
x-ray (CXR) was done post compressions and compared to CXR done pre-compression.
It was noticed that the Impella device was displaced. Labs indicated hemolysis with high lactate
dehydrogenase (LDH) 1554 Units/L (normal range 94-250 Units/L) and low haptoglobin 26 mg/dL (30200 mg/dL). Displacement was confirmed with transthoracic echocardiography (TEE) and the Impella
was repositioned. Unfortunately, the patient deteriorated clinically, family withdrew care and he died
the next day.
Discussion: The use of Impella devices is surging. Displacement of Impella has been rarely reported,
however, it can be a catastrophic resulting in increased intravascular hemolysis and cardiovascular
compromise. In the event of chest compressions, patients should have TTE or CXR to localize the
position of Impella. Routine measurement of markers of hemolysis can also help in timely detection of
ongoing hemolysis.
Unsuccessful Suicide Attempt: A Remarkable Recovery from Depakote
First Author: Aubrey N Schmidt, MD Arshid Pandit, MD, Imran Mir, MD
Introduction: Depakote (valproic acid) is widely used to treat seizures, bipolar disorder, and migraines. It
was originally approved as an anticonvulsant by the FDA in 1978 and was approved in 1995 for
treatment of bipolar disorder. Over the past decade, cases of overdose have been increasing. Depakote
increases levels of gamma-aminobutyric acid and prolongs the recovery of inactivated sodium channels,
acting as a central nervous system (CNS) depressant. Depakote may also cause impairments in fatty-acid
metabolism and disrupt the urea cycle, leading to hyperammonemia.
Case presentation: 27 year old female presented in a coma after ingesting 32 tablets of Depakote 500
mg, as a suicide attempt. She presented with findings of severe valproic acid poisoning including coma,
hypernatremia, hyperammonemia, and a rare complication, cerebral edema. Poison control
recommended emergent hemodialysis, and L-carnitine supplementation. Activated charcoal was not
administered due to lack of bowel sounds. She was placed on hypothermia protocol and
ventriculostomy was performed for cerebral edema. She miraculously recovered and was transferred to
an inpatient psychiatry facility for suicide attempt.
Conclusion: Therapeutic ranges of Depakote are 50-100 mg/L. The half-life of Depakote varies from 5-20
hours, and up to 30 hours in those with an acute overdose. Serious intoxication is likely at levels greater
than 450 mg/L and coma, metabolic acidosis and hemodynamic instability occurs over 850mg/L.
Cerebral edema can occur 48-72 hours after ingestion. Elevated serum ammonia levels can produce
encephalopathy leading to neuronal injury as well as disruption of the osmotic gradient, which is
thought to cause cerebral edema.
Unusual presentation of Hypothyroidism
First Author: Samer Kanno,MDMohammed Shaik,MD;Rasha Nakhleh MD;Ghassan Bachuwa,MD
Introduction: Thyroid hormone plays a role in regulation body metabolism ,patient with
hypothyroidism usually presents with weight gain, decreased exercise tolerance, cold intolerance and
edema, although cardiovascular symptoms are not so prominent in patient with hypothyroidism
,hypertension and CHF are well known cardiac manifestation of hypothyroidism due to increase in
serum aldosterone and norepinephrine concentration and subsequent effects on the rennin-angiotensin
system and increase the peripheral resistance. We are presenting a case with recurrent episodes of
hypotension with severe hypothyroidism.
Case Presentation: A 55 year old gentleman with significant past medical history of DM, CHF with low
EF s/p AICD,ESRD on HD, normal TSH one year back, admitted to the hospital for syncopal episode
,hypotension and anasarca. For the last few month the patient had a multiple admission syncopal
episode and relative hypotension ,extensive workup for syncope was done including carotid Doppler,
AICD interrogation and Echocardiography were ,all were negative ,cortisol and ACTH level were normal
too , blood pressure continued to run on the low side (systolic 80's-90's). His condition continued to wax
and wane including mentation and vital signs .Subsequently the patient developed progressive
obtundation, hallucination and decreasing mental alertness. His laboratory results showed evidence of
severe hypothyroidism with myxedema coma. Patient's TSH was over 180. Patient required transfer to
the intensive care unit where patient received intravenous hydrocortisone as well as intravenous
thyroxin with significant improvement in his blood pressure, mental alertness and general status.
Patient was subsequently transferred to the medical floor. He had shown significant improvement in his
TSH level and he was switched to PO thyroxin. After was stabilized on the medical floor , he developed
cardiac arrest and was transfer to ICU , given his comorbidities and poor condition the family decide to
change code status to NEM.
Conclusion: Hypothyroidism should be considered in patient with prolonged unexplained hypotension.
This is a case of prolonged history of hypotension secondary to decrease thyroid hormone. This patient
exhibits atypical presentation of severe hypothyroidism regarding blood pressure homeostasis; this
raises the need of early recognition and prompt management of this potentially critical condition.
Pellagra dermatitis in a patient with carcinoid
First Author: Tania Jain, MD Manmeet Singh, MD
Introduction: Carcinoid tumors are uncommon and originate from the enterochromaffin cells producing
neuroendocrine mediators like serotonin. Pellagra as a complication of carcinoid tumor, although well
recognized, has not been commonly reported.
Case description: We describe a 64 year old woman who presented with skin lesions which started on
legs and then progressed to the anterior abdominal wall, back and arms. There was no itching or burning
sensation. She had a history of diagnosis of biopsy-proven carcinoid tumor of the duodenum. Past
history was also significant for heart failure, diabetes and rheumatoid arthritis. On examination, vitals
were stable without hypotension or tachycardia. Dermatological examination was significant for
multiple hyperpigmented macules ranging from a few millimeters to 3-4 centimeters in size, distributed
over all four extremities, anterior abdominal wall, chest wall and back. Palms and soles were spared. The
macules had well demarcated margins and superficial scaling. No bullae, pustules or surrounding
erythema were present. Peri-oral and peri-orbital hyper-pigmentation was also noted. Lower
extremities were noted to be edematous. Cardiac, lung and abdomen exams were normal. Other than
mild elevation in alanine aminotransferase to 79 U/liter and hemoglobin low at 10.9 gm/dl (MCV 82.2
FL), labs were within normal range. At the time of diagnosis of carcinoid, CT scan of the abdomen had
shown 1.8 cm nodule marginating the duodenum and pancreatic head. PET scan was significant for
areas of increased uptake in antrum and proximal duodenum. Octreotide scan had revealed increased
uptake in lower abdomen adjacent to the aorta. Endoscopy and biopsy of the lesions were diagnostic for
a well-differentiated neuroendocrine tumor. At the time of current admission, we suspected pellagra
dermatitis secondary to carcinoid. This was based on clinical features and history of carcinoid.
Dermatological consultation was obtained, who confirmed the diagnosis. Niacin replacement was
started and we are currently following the progress of the patient.
Discussion: Although pellagra is clinically described as a triad of dermatitis, dementia and diarrhea; all
these features are not present in a majority of patients (Per Spivak et al, all 3 entities were seen in only
22% patients). Dermatitis as a sole manifestation of pellagra is not uncommon and was seen in one-third
of the patients by the same group. In carcinoid syndrome, tryptophan metabolism is diverted towards
synthesis of serotonin, thus, leading to reduced availability for niacin synthesis. Among other
dermatological manifestations of carcinoid tumor, pellagra and resultant dermatitis is a well-known
entity but less well versed to physicians. We report this relatively uncommon case to draw attention to a
treatable aspect of this complex condition.
Hemophagocytic lymphohistiocytosis in Infliximab -associated Disseminated
First Author: Imad Bagh, MD, Kwabena Adu-Gyambi, MD, Shafik Boyaji, MD, Lorenzo Zaffiri, MD, Susan
Bannon, MD, FACP.
Introduction: Patients treated with tumor necrosis factor (TNF) blocking agents are susceptible to
infectious complications due to immunosuppression. We present a case of persistent fever, night sweats
and weight loss that was later diagnosed with disseminated histoplasmosis. We believe that in our
patient the pancytopenia was due to Hemophagocytic Lymphohistiocytosis (HLH) which has rarely been
reported in association with disseminated histoplasmosis.
Case Presentation: 27 year-old male with history of ulcerative colitis treated with Infliximab, presented
with fever, night sweats, nausea and diarrhea for two weeks. The patient reported 5 lb weight loss. On
exam, hepatosplenomegaly was noted with the spleen being palpable 4 cm below the left costal margin.
A CT of the chest showed numerous tiny pulmonary nodules in a miliary pattern with extensive
mediastinal lymphadenopathy. Before starting the Infliximab treatment he had negative PPD test with
no history of tuberculosis exposure but he has significant environmental exposure to Histoplasma
A CBC and comprehensive metabolic panel showed WBC 3.5 Thous/CMM, Hemoglobin 12.3 gm/dl,
Platelets 101 Thous/CMM, AST 480 U/L, ALT 698 U/L and normal alkaline phosphatase of 101 U/L. A CT
of the abdomen and pelvis confirmed the hepatosplenomegaly with the spleen measuring 18 cm and
the liver measuring 21 cm. An extensive work-up revealed positive fungitell assay of 275 pg/ml
indicating systemic fungal infection, both histoplasma antibodies and antigen were positive in the serum
with positive urine histoplasma antigen. Although the bronchoalveolar lavage and bone marrow fungal
culture did not show any growth after 28 days, the quick response to the liposomal amphotericin with
resolution of the symptoms and the fever within 48 hours supported the diagnosis of disseminated
The patient met the diagnostic criteria for HLH where he had fever, splenomegaly, hepatitis, ferritin of
1574 ng/ml, and soluble IL 2 receptor level of 13712 unit/ml. The diagnosis was confirmed by a bone
marrow biopsy showing hemophagocytosis. The patient had an excellent response to the liposomal
amphotericin treatment and on discharge he had normal WBC and platelets count with normal AST and
ALT of 53 U/L.
Conclusion: Hemophagocytic Lymphohistiocytosis is an aggressive and potentially live threatening
disease that has been associated with viral infection, bacterial infections and rarely with fungal
infections. We believe that our patient had HLH secondary to disseminated histoplasmosis, successfully
treated with Liposomal Amphotericin. Given the diagnostic challenges and the mortality risk in
immunocompromised patients, the possibility of HLH secondary to underlying infection should be
considered in every immunocompromised patient presenting with fever, hepatitis and pancytopenia.
Pseudomyxoma Peritonei as a rare cause of abdominal pain in a 62 year old
First Author: Karim Al Azizi MD , Egbert Liquete MD, Rami Alassaad MD, Ibrahim Saad MD, Dalia Shibeika
MD, Mazen Alsaqa MD, Marcum Collins MS
Background: Pseduomyxoma Peritonei is used to describe a clinical syndrome associated with a subtype
of mucinous appendiceal tumors that lead to an accumulation of mucinous ascites. As the tumor grows,
mucin accumulates, eventually leading to appendiceal rupture. This rupture of the appendix results in
seeding of the peritoneal cavity with mucin-producing cells which continue to grow and slowly fill the
peritoneal cavity. The Netherlands Cancer Institute noted an incidence of nearly 2 cases per million per
year. Patients, more commonly women, typically present with increasing abdominal size/distention,
abdominal pain, new ovarian mass, or overt bowel obstruction.
A 62 yo female presented to the ER having been sent by her family physician after an abnormal
ultrasound. She was complaining of vague RLQ pain, rated 2/10, non-radiating, for about four weeks.
She confirmed nausea, but no vomiting. She also confirmed fatigue, anorexia, and occasional diarrhea.
She noted that the area was tender to palpation, and denied fever/chills and dysuria. Transpelvic
endovaginal US showed a hyperechoic complex cystic structure with rim-like calcifications in the RLQ, as
well as a moderate amount of complex fluid throughout the pelvis. In the ER, a CT scan of the
abdomen/pelvis showed a RLQ fluid collection with peripheral capsule, and extensive complex free
intraperitoneal fluid suggestive of a chronic appendicitis with rupture. CA 125 and CA 19-9 were WNL,
while CEA was elevated at 6.8 ng/ml. Paracentesis revealed a thick, gelatinous, opaque yellow fluid
which was negative for malignant cells indicative of mucinous carcinoma, and consistent with the
radiographic impression of Pseudomyxoma Peritonei. Exploratory laparotomy with appendectomy and
debulking procedure were performed. Anatomic pathology of the appendiceal mass revealed a
mucinous cystadenoma with rupture, and extension of mucin into the peritoneal cavity, thereby
confirming the diagnosis of pseudomyxoma peritonei.
Conclusion: With intestinal obstruction being a common cause of death in these patients,
Pseudomyxoma Peritonei is a rare pathology whose early diagnosis is paramount for any female
presenting with a new pelvic mass or insidious onset of abdominal distention.
Atypical Presentation of Immune Reconstitution Inflammatory Syndrome
(IRIS) in HIV patient
First Author: Syed A Hussain, MD; Jyotsna Ganta, MBBS; Ali Sabbagh, MD; Wasif Hafeez, MD
Introduction: Immune Reconstitution Inflammatory Syndrome (IRIS) is a display of immune system
hyper-reactivity following initiation of anti-retroviral therapy (ART) in HIV positive patients characterized
by paradoxical worsening of underlying opportunistic infection. While IRIS presents within weeks of
initiation of ART, it rarely can manifest as late as two years.
Case Presentation: A 45-year-old African American male with HIV diagnosed in 1994 on ART presented
to the emergency department with altered mental status and left sided weakness. Physical exam
revealed a confused male, oriented only to person, with right-sided gaze and left sided motor deficit. CThead was negative for intracranial bleed and laboratory results within normal limits. CD4 count was 300
with viral load of 1430. Lumbar puncture revealed low copy Epstein Barr viral load by PCR, EEG showed
Periodic Lateralizing Epileptiform Discharges indicating cortical hyperirritability. In concert with CSF
findings, patient was treated for viral encephalitis and given seizure prophylaxis. Two months later he
was readmitted for weakness and memory loss. After extensive workup for infectious etiology returned
negative, MRI guided brain biopsy revealed considerable perivascular and parenchymal inflammation by
monocytic/macrophage cells immunoreactive to HIV, raising the specter of IRIS. CD4 count was now 418
with viral load of 371. A trial of steroids was given and within days, patient’s neurological symptoms
showed dramatic improvement, while ART was also continued.
Conclusion: This case illustrates the importance of considering IRIS in an HIV patient with clinical
deterioration on ART due to flare-up of latent underlying opportunistic infection. With more effective
drugs available in the ART arsenal, there has been a reduction in AIDS related complications as well as
IRIS. It is paramount to keep this entity in the differential in an HIV positive patient and while it is more
commonly seen with low CD4 count, there are case reports of IRIS manifesting quite late while on ART.
Management for IRIS includes continuing ART with possible steroid use and in rare cases with life
threatening consequences, ART maybe discontinued.
Bortezomib induced Hepatitis B reactivation: a unique phenomenon
First Author: Salwa Hussain, MD, Jeffrey Najor,MD Pamela Moore,RN Muhammad Ahsan,MD Samira
Ahsan, MD Robert Bloom, MD Providence Hospital and Medical Centers, Southfield, Michigan
Introduction: It has recently been reported that hepatitis B (HBV) reactivation in patients with
lymphoma who are hepatitis B surface antigen (HBsAg) negative during or after cytotoxic therapy occurs
after the use of rituximab and stem cell transplantation.1 However, clinical data on HBV reactivation in
multiple myeloma (MM) patients has not been extensively reported. Bortezomib , a selective
proteasome inhibitor, and lenalidomide have had remarkable activity in relapsed/refractory multiple
myeloma (MM).2 Although they are well tolerated with a manageable toxicity profile, reactivation of
viral infections may emerge as a problem in this setting.2 Here, we present a case of MM who developed
hepatitis B reactivation after bortezomib and lenalidomide therapy.
Case: A 73-year-old Russian female who had history of marginal cell lymphoma diagnosed in 2006 was
monitored without needing therapy. In 2009, she developed MM, presenting as a plasmacytoma
requiring vertebral decompression and focal radiation. While on therapy she suddenly developed renal
failure and was started on bortezomib and doxorubicin. After a transient response to 5 cycles, she was
switched to lenalidomide. Prior to therapy she was seropositive for anti HBs and HBc with negative
HBsAg indicating a prior natural infection. Her aminotransferase level was normal. She was serially
monitored for hepatitis serology at dialysis with seroconversion in August of 2008, one month after her
change in therapy. Tenofovir was started and patient recovered her immune status within a few months
of therapy. Naranjo adverse drug reaction probability score was 5.
Discussion: Bortezomib has a significant risk of reactivation of infection by the varicella zoster virus3 and
acyclovir prophylaxis is recommended.4 A single case report describes reactivation of hepatitis B after 10
cycles of bortezomib treated with entacavir.5 Bortezomib-associated late hepatitis B reactivation
appears to be a unique event which requires further confirmation. The contribution of one cycle of
lenalidomide to this seroconversion is unknown.
Learning point: Seropositive patients may benefit from serially monitoring for hepatitis B activation
while on Bortezomib therapy.
1. Beysel S, Yegin ZA, Yagci M. Bortezomib-associated late hepatitis B reactivation in a case of multiple
myeloma. Turk J Gastroenterol. 2010 Jun;21(2):197-8.
2. Tong Y, Qian J, Li Y, et al. The high incidence of varicella herpes zoster with the use of bortezomib in 10 patients.
Am J Hematol 2007; 82: 403-4.
3. Wu KL, Van Wieringen W, Vellenga E, et al. Analysis of the efficacy and toxicity of bortezomib for treatment of
relapsed or refractory multiple myeloma in community practice. Haematologica 2005; 90: 996-7.
4. Vickrey E, Allen S, Mehta J, Singhal S. Acyclovir to prevent reactivation of varicella zoster virus (herpes zoster) in
multiple myeloma patients receiving bortezomib therapy. Cancer 2009; 115: 229-32.
5. Tanaka H, Sakuma I, Hashimoto S, Takeda Y, Sakai S, Takagi T, Shimura T, Nakaseko C. Hepatitis B reactivation in
a multiple myeloma patient with resolved hepatitis B infection during bortezomib therapy: case report. J Clin Exp
Hematop. 2012;52(1):67-9
Cannabis: An uncommon Cause of Myocardial Infarction in a Young Patient?
First Author: Alpesh K Korant, MD Rajitha Valsan, MD Nicole Gallagher, MD Susan Smith, MD
Introduction: One third of all Americans aged 12 years and older have used marijuana or hashish at least
once in their lifetime. It is one of the most commonly abused illicit drugs in the United States. Marijuana
triggering myocardial infarction, in the presence of risk factors, has been described in the age group
prone to coronary artery disease. Myocardial infarction due to marijuana use as a sole risk factor in
younger patients has not often been reported.
Clinical Vignette: A 27 year old man with no past medical history and no coronary risk factors was
admitted with sudden onset typical chest pain. The chest pain was associated with nausea, shortness of
breath, diaphoresis, palpitations and light headedness. He was having intermittent exertional chest pain
for 14 days. The patient admitted to excessively smoking marijuana for an ongoing toothache for over
20 days. Initial EKG showed sinus rhythm with complete right bundle branch block, anteroseptal ST
segment elevation and T wave inversion in the inferior leads. CT scan of the chest without contrast ruled
out pulmonary embolism. The left heart catheterization revealed normal coronary anatomy.
Discussion: Cannabinoid receptors belong to the G protein-coupled receptors family. CB1and CB2 are
two main subtypes of cannabinoid receptors. These receptors are present in various areas of the brain,
immune system, blood vessels and the heart. Dose-dependent effects of marijuana increase the resting
heart rate, blood pressure, myocardial oxygen demand and carboxyhemoglobin, the latter leading to a
decreased oxygen supply to the myocardium. In addition, oxidant gases produced by marijuana smoking
result in cellular stress, causing platelet activation, increased oxidation of LDL, stimulation of Factor VII
activation and the production of an inflammatory response. As a result, smoking cannabinoids has been
described to decrease anginal threshold, increase thrombus formation and trigger myocardial
Conclusions: We conclude that cannabis smoking may be an independent risk factor for the increasing
prevalence of myocardial infarction among the younger population. This is an increasingly important
issue to publicize in view of the lay population’s belief that smoking cannabis is harmless and should be
First Author: Rizwan Khan, MD, Chandrakant C. Desai M.D., Thomas J. Piskorowski D.O.
Introduction: Posterior Inferior Cerebellar Artery (PICA) infarcts present with a spectrum of symptoms.
These can range from generalized symptoms such as headache, vomiting, difficulty swallowing, and
slurred speech. More specific symptoms of cerebellar infarcts include ataxia, vertigo, nystagmus, and
palatal myclonus. Rarely do we see signs of total paralysis of the entire body as if the patient were
presenting with Locked in Syndrome.
Case Presentation: We present a case of a 62 year old gentleman with a past history of hypertension,
congestive heart failure, diabetes mellitus, and chronic kidney disease who was brought to the ICU after
the patient’s mother woke up early in the morning to find the patient vomiting. This was followed by
mental status changes where the patient was very lethargic and snoring loudly. In the days leading up to
his admission to the hospital, the patient’s mother mentioned that the patient was complaining of
feeling off balance while walking. A detailed neurological exam in the ICU showed slurred speech and
palatal myoclonus. However, the most striking finding was the paralysis of the entire body and inability
to verbalize but his cognitive abilities were intact. He was able to open his eyes and follow simple
commands using eye movements. This strongly suggested a locked in syndrome. A computerized axial
tomography scan and magnetic resonance imaging of the head/neck showed a wedge shaped
hypodensity in the posteriomedial aspect of the right cerebellum and vermis suggesting a right PICA
infarct with minimal mass effect on the 4th ventricle. In addition, a magnetic resonance angiography
showed extension of the infarct into the brainstem medulla, but leaving the basilar artery intact. The
patient was subsequently intubated, given a dose of mannitol to keep his osmolality less than 320
mOsm/kg. He was also started on hypertonic saline with a goal sodium of 150-160 mEq/L. Once the
patient was off the sedation, further neurological followup revealed that the patient was eventually able
to wiggle his toes and fingers bilaterally. The patient subsequently went for rehabilitation where he
recovered some of his motor functions.
Discussion: Although PICA infarcts cause mild symptoms of dizziness and ataxia, the rare and
devastating findings of quadriplegia from a PICA infarct shows how an occlusion in the distal or proximal
PICA determines the severity of symptoms. A thorough neurological exam will not only give one a better
idea as to where the occlusion lies and the ischemic areas that are affected by the occlusion but will
determine which bodily functions will be affected and to be managed appropriately.
A 62-year-old male with progressive dyspnea and dry cough
First Author: Adeeb Bulkhi, MD, Ahmad Hamad, MD, Ayman Soubani, MD,
Introduction: Brochoalveolar carcinoma (BAC) is a subtype of lung adenocarcinoma strictly
characterized histologically by a pure lepidic growth without any invasion of stroma, blood vessels, or
pleura. BAC is unique in that it is characterized by distinct clinical, radiographic, and histologic
characteristics. Risk factors for the development of BAC include young Asian female, prior tuberculosis,
progressive systemic sclerosis with related pulmonary fibrosis or scarring, congenital pulmonary airway
malformation, occupational exposure, and previous exogenous lipid pneumonia
Case report: We are reporting a 64-year-old African American man was admitted to the hospital for
progressive exertional dyspnea and dry cough for 2 weeks. There were no fever, chest pain, orthopnea,
paroxysmal nocturnal dyspnea, hemoptysis, and weight loss. He had 30-pack year history of tobacco use
but quit 1 year ago. No recent travel or TB exposure. His medical history included cerebrovascular
accident with residual minimal right side weakness and compensated cardiomyopathy. Surgical and
family histories were unremarkable. He was in mild respiratory distress without hypoxia otherwise
normal vital signs. Fine bibasilar crackles heard. Laboratory studies were normal. Chest x-ray showed
diffuse reticulonodular opacities. Chest CT scan with contrast revealed extensive alveolar filling
infiltrative process throughout both lungs. Interestingly, on chest radiography taken 6 months ago did
not show any abnormality. With this relatively acute presentation, infectious and autoimmune etiologies
were higher in the list. Autoimmune serologies, which included ANA, ANCA, and RA, were negative.
Respiratory cultures Acid-fast bacilli smear and PPD skin testing were negative. Fungal antibodies to
histoplasma, blastomyces, and coccidioides, as well as Aspergillus, were not detected. HIV test was nonreactive. Bonchoscopic Alveolar lavage with endobronchial biopsy was done. Fluid wash cultures were
negative. The histopathological specimen revealed a well-differentiated adenocarcinoma with
bronchoalveolar or lepidic growth pattern. Gene testing also showed a deletion mutation detected
within exon 18 of the EGFR gene. Staging work-up did not reveal any bone enhancement on wholebody PET scan. He was offered palliative chemotherapy; he had 3 cycles of chemotherapy then he opted
to be under hospice care. Four months later, the patient deceased.
Discussion: BAC is rarely seen in elderly male patients. It is highly prevalent in young East Asian
female, Interestingly, BAC has no or less smoking association or history compared to other lung cancers.
BAC is slow growing tumor and relatively maintained differentiation. It is most of the time BAC
discovered incidentally on routine chest imaging. 5-year survival rate is excellent in some BAC types. This
case illustrates how acute BAC can present. Physician should keep in mind malignancy as possible cause
of diffuse radiological findings in acute presentation. Early diagnosis, staging and treatment of BAC has a
good prognosis in most subtypes.
Stenting for an intrasellar mass
First Author: Sudarshan Paudel, MBBS, Luis Ospina, MD, Omar M Qahwash, DO
Introduction: Intrasellar aneurysms are rare, but can often mimic pituitary masses. Confirmation of the
diagnosis with magnetic resonance angiography (MRA) or CT angiography (CTA) is important to avoid
catastrophic outcomes.
Case Description: 63 year old lady presented to the hospital with excruciating frontal headache
associated with nausea and vomiting after she fell from her chair and landed on her back. She had been
having mild headaches, especially in the mornings, for last couple of months and they were getting
worse for the last few weeks. She denied any neurological symptoms, visual changes, seizure like
activities, lactation or polyuria. On examination, she was neurologically intact without any visual field
deficits. Past medical history was significant for nephrolithiasis, urinary tract infection and ventricular
tachycardia while surgical history included hysterectomy. Family history was unremarkable. She has
never smoked but enjoys alcohol on social occasions. She is allergic to sulfa drugs and eggs. CT scan of
head showed a soft tissue density filling the sellar region and extending into the left cavernous sinus.
There was significant increase in the size of the mass with bony erosion of dorsum sellae when
compared with the CT scan from 2005. In 2005 she was advised for MRA of brain after the CT findings of
the pituitary mass but she never got one until now. Hormonal studies showed normal levels of prolactin,
growth hormone, thyroid stimulating hormone and luteinizing hormone while follicle-stimulating
hormone was appropriately elevated for postmenopausal state. Subsequent MRA of brain was
suggestive of a partially thrombosed internal carotid artery (ICA) aneurysm extending into the sellar
region. ICA arteriogram confirmed a saccular aneurysm measuring 25 mm with 1cm broad neck
originating from the horizontal segment of the petrous segment of left ICA. She was discharged home
after a successful stenting across the neck of the aneurysm with the pipeline embolization device.
Discussion: Intrasellar aneurysms are rare and can mimic a pituitary tumor or cystic lesion. Almost all of
such aneurysms are reported as case reports. Majority of the unruptured intrasellar aneurysms present
with symptoms of mass effect, headaches, visual changes or symptoms of pituitary endocrinopathies.
Less often does an unruptured intrasellar aneurysm present with acute worsening of headache, like this
case. Aneurysms should always be considered in the differential diagnosis of all sellar masses.
Appropriate diagnosis with CTA/MRA is important before any intervention is undertaken, as cases with
catastrophic outcomes have been reported where aneurysms were wrongly intervened for a pituitary
A Rare Case of Idiopathic Collapsing Focal Segmental Glomerulosclerosis That
Responded to Steroid Treatment
First Author: Alaa Abu-Sayf, MD Sulaiman Alhassan, MD, and David R. White, MD
Introduction: Out of the five histological types of FSGS, the collapsing variant carries the worst
prognosis, some features of FSGS include frequent association with HIV infection, predominance in
blacks, massive proteinuria (>10g/day), resistance to treatment and rapid progression to end stage renal
Case report: A 51-year-old Jamaican-American woman with a history of hypertension, presented with
flu-like symptoms for one month with no recent use of NSAIDS, interferon, bisphosphonates or
intravenous drugs. On physical exam, bilateral lower extremity pitting edema was appreciated. She was
diagnosed with nephrotic syndrome with 17 grams/day of proteinuria with a (Cr) of 5.4 mg/dl. Our
workup ruled out SLE, ANCA-associated vasculitis, multiple myeloma, HIV (nuclear amplification test also
done), viral hepatitis and other infections associated with this diagnosis. Two renal biopsies confirmed
the diagnosis of collapsing variant of FSGS, with tubuloreticular inclusions (TRIs) identified under
electronic microscope. Treatment was started with pulsed methylprednisolone 1 gram for 3 days
followed by 40 mg of prednisone daily. Six weeks into treatment, Cr fell to 2.6 mg/dl and proteinuria
was down to 4.7 g/d. Partial remission was achieved after fifteen weeks with a Cr of 1.8 mg/dl and
proteinuria of 1.7 g/d. Prednisone is currently being tapered down to complete a course of six months.
Discussion: The diagnosis of idiopathic collapsing FSGS was confirmed by renal biopsy in the absence of
secondary causes. The combination of TRIs in our patient‘s biopsy and the negative serology for HIV
challenges the previously reported strong association between them in the literature.
Our patient’s black race, the presence of advanced kidney dysfunction at the time of renal biopsy and
the degree of tubular atrophy were predictors of a worse outcome.
We think that our patient’s response to steroids despite her poor prognosis enriches the literature
available for similar cases. Out of 5 cases reported by Weiss el al in 1994, only one responded to
corticosteroids. Furthermore, in 1996 Valeri el al showed no remissions in 26 cases treated with steroid;
however, a remission rate of 14% was achieved with other immunosuppressive agents used after steroid
failure. Clinical safety of corticosteroids compared to other immunosuppressants along with the existing
data may justify their use in the initial management. On the other hand, delaying immunosuppressive
therapy in cases of steroid resistant FSGS may alter the final outcome.
Conclusions: Idiopathic collapsing FSGS with presence of TRIs in the renal biopsy and negative HIV
workup, a rare entity, seems to have significant response to steroids even at an advanced stage of
kidney disease. Evidence based case series would be needed for determination of optimal initial
Waanbah, MD
Actinomyces israelii Masquerading As An Intercostal Sarcoma In A Low Risk
First Author: Barryton Decruse Waanbah, MD Second Author: Victor Velocci, MD Third Author: Dunstan
Mascarenhas, MD Fourth Author: Aftab Ahmad, MD
Introduction: A 63 year old gentleman with a history of diabetes presented with a painful, progressively
enlarging mass in the right flank for 4 weeks associated with a serosanguineous discharge for 3 days.
There was no recent history of oral infections, recent periodontal work, trauma or bites. He reported
night sweats and a 20 pound weight loss over the previous month which he attributed to decreased
appetite. No history of fever, recent outdoor activity, travel or exposure to sick contacts was expressed.
He is a retired welder and lives at home.
Case Presentation: Clinical examination revealed a tender, indurated mass on the right lumbar region
with serosanguineous discharge. No palpable lymphadenopathy in any lymphatic groups was present.
Computerized tomography (CT) of the chest and abdomen showed an opacity measuring 10x15 cm with
direct invasion of the liver and perirenal fat, suggestive of sarcoma. The lesion extended through the
intercostal spaces into the soft tissues external to the ribs without rib erosion. A moderate right pleural
effusion was seen. Core biopsy of the mass revealed numerous branching, small hyphae-like structures
on Gomori's methenamine silver stain. Modified acid fast stain, periodic acid-Schiff stain, Gram stain,
and aerobic culture were negative for any microorganisms. An incisional biopsy was subsequently done
and a histopathological examination strongly suggested actinomyces. Anaerobic culture grew
Actinomyces israelii. The patient is currently being treated with amoxicillin. His immunological studies
for other fungal infections and human immunodeficiency virus were negative and he is recovering well.
Discussion: Actinomycosis is a chronic suppurative infection commonly seen in tropical countries. It is
caused by Actinomyces israelii, a part of the normal flora of the oral cavity. Lesions typically present on
the neck, thorax and abdomen and generally develop endogenously from oral disease. Primary
cutaneous actinomycosis is extremely rare due to the endogenous habitat of the organism. Cutaneous
lesions occur by direct contiguous extension from an underlying primary focus or by hematogenous
dissemination during the septicemic phase of the infection, in which case there are often multiple
lesions. The majority of the cases reported have had a clear history of trauma, either a human bite or a
perforating injury with contamination from outside. Our patient had none of these risks. It is worth
noting that the CT scan suggested sarcoma as the most likely diagnosis when in reality a treatable
infection was the correct finding. To our knowledge this is the first reported case of primary cutaneous
actinomycosis in the western hemisphere. As actinomycosis is amenable to medical treatment, early
diagnosis saved the patient from the burden of many surgical procedures.
A Case of Unusually Aggressive Evans Syndrome
First Author: Shaheer Zulfiqar, MD Second Author: Adnan Bhopalwala, MD Third Author: Sana Syed, MD
INTRODUCTION: Autoimmune hemolytic anemia is a common diagnosis and the disease is often well
controlled with modern treatment regimens. However, it may also occur as a part of a more complex
disease associated with greater dysfunction of immune regulation. One such example is Evans
syndrome. It is characterized by Autoimmune Hemolyitc Anemia, Immune Thrombocytopenia or
Immune Neurtropenia, occuring either simultaneously or sequentially. In such instances treating the
anemia can be difficult and poses a significant morbidity and mortality risk for the patient. Evans
syndrome has a chronic course with periods of remission and relapse. Here we present a case of Evans
syndrome, with autoimmune hemolytic anemia and a prior history of ITP, which was more aggressive
than previously reported.
PATIENT DESCRIPTION: The patient was a middle aged man who presented with fatigue and night
sweats for three months, followed by yellowish discoloration of the skin and eyes for two weeks. The
patient also had a history of ITP, which had been treated successfully, however the patient had lost
contact with his hematologist because of the doctor’s relocation to another state.
INTERVENTIONS: The patient’s diagnosis of hemolytic anemia was established through measurements of
hemoglobin level, haptoglobin level, LDH levels, Coombs test and pathologist review of peripheral blood
smear. Other causes of hemolysis were ruled out. He was initially treated with intravenous
corticosteroids; however his hemoglobin continued to fall. Hematology was consulted, and the patient
was started on Cellcept, however with little effect and the patient now required frequent transfusions.
Immunology was consulted who on further serologic studies, the patient was found to be ANA positive
but with a negative reflex screen. The patient then received treatment with four cycles of intravenous
immunoglobulin, with no improvement and was subsequently started on Rituximab. He failed to
respond and now his platelet levels also began to fall. It was decided that the patient should have a
splenectomy. The patient’s preoperative course was complicated by a pulmonary embolism, for which
he received an IVC filter. The patient underwent the splenectomy however the post operative course
was complicated by bleeding from the surgical site and Clostridium difficile colitis. Although the patient’s
hemoglobin did stabilize somewhat, he continued to do poorly, was made comfort care and expired.
CONCLUSION: Evans syndrome is a rare disorder involving significant immune dysfunction. This disorder
presents a significant therapeutic challenge. Although more common in children, cases have been
reported in adults. We believe that our patient did have Evans syndrome. The diagnosis warrants
specific follow up as it is associated with a higher incidence of other autoimmune disorders as well
as malignancy. Furthermore, in the case of our patient, the anemia was very aggressive with
deterioration over weeks, rather than a chronic course, as has been previously reported.
Asymptomatic Complete Heart Block: Can one survive without impulse
Brijesh Patel DO, Aleghen Gelaye MD, Saba Darda MD, Souheil Saba MD
Introduction: Symptomatic advanced heart block is well known phenomenon in medicine but
asymptomatic complete heart block is uncommon. It can be caused by wide variety of reasons including
infection, drugs, autoimmune, and infiltrative conditions such as sarcoidosis. Asymptomatic complete
heart block, however, has been rarely associated with sarcoidosis. We present a case of asymptomatic
complete heart block during a routine pre-operative screening for a diagnostic procedure for lung
nodules that turned out to be sarcoidosis.
Case Description: A 42 years old African American Male who came to the hospital for scheduled
bronchoscopic evaluation of multiple bilateral lung nodules and mediastinal adenopathy that were
found on CT scan of the chest. The Past medical history is significant for Hypertension, Non-ischemic
Cardiomyopathy with Ejection Fraction of 35%, sudden cardiac arrest, left-sided Cebebrovascular
accident with residual weakness and Chronic Kidney Disease. His home medications include Aspirin,
Carvedilol, Minoxidil, Imdur, Keppra and Baclofen. Patient had asymptomatic bradycardia with normal
other vital signs. On the physical exam, patient has rash that appears to be bluish-red maculopapular
lesion that started on the forehead and descended down to upper abdominal area. Routine pre-op
electrocardiogram showed complete heart block with right rundle branch block for which he received
emergent Bi-ventricular Intracardiac Device with epicardial leads. The echocardiogram showed Severe
concentric left ventricular and mild right ventricular hypertrophy, global impairment in LV contractility,
and Ejection Fraction of 35%. The left biopsy revealed multiple granulomas, most likely representing
sarcoidosis. Histochemical stains for acid fast bacilli and fungal organisms are negative. Based on the
biopsy result, he was started on prednisone 60 mg intravenously to be converted to oral and tapered
off. Since the initiation of steroid therapy, his rash noticeably improved. During his stay in the hospital,
the patient remained asymptomatic and in paced rhythm.
Discussion: The diagnosis of cardiac sarcoidosis is challenging and a high index of suspicion is critical.
However, it can be made based on Japanese Society of Sarcoidosis and Other Granulomatous
Disorders criteria revised in 2006. Our patient meets two out of four major criteria suffice to diagnose
Cardiac Sarcoidosis: (1) Advanced AV block (Third-degree Heart block with Right Bundle Branch Block)
and (2) Ventricle Ejection Fraction (EF) less than 50%. Patients with unrecognized and untreated
Cardiac Sarcoidosis may experience severe symptoms or fatal arrhythmias prompting immediate
intervention. Asymptomatic complete heart block, although rare, often can be fatal. Therefore, prompt
recognition and treatment of underlying cause is warranted in these patients.
Urgent Filter-Protected Thrombectomy and Percutaneous Angioplasty with
Stent for Acute Vertebral Artery Thrombosis and Stenosis
Sayf Al-Tabaqchali, M.D., Ziad Kanaan M.D., Ph.D., Garima Agrawal, M.D., Zain Kulairi, M.D., Ahmadreza
Firouzgan, M.D., Samer Y. Kazziha, M.D.
INTRODUCTION: The main cause of extracranial vertebral artery stenosis is atherosclerotic disease that
often develops at flow dividers and branch points, where both turbulence and shifts in shear stress exist.
Less commonly, pathologic processes including trauma, fibromuscular dysplasia, Takayasu disease,
osteophyte compression, dissections, and aneurysms can also affect the extracranial vertebral arteries.
DESCRIPTION: LS is a 56-year-old Caucasian gentleman with a previous history of hypertension and
dyslipidemia who presented with dizziness, vertigo, nausea, vomiting, and a syncopal event prior to
admission. He initially presented to another hospital with complaints of visual disturbances and
dizziness and was discharged with a prescription for Meclizine. On the day of admission, the patient had
a syncopal episode followed by worsening of his symptoms for which he presented to our facility.
Patient is a known 40-pack year smoker, consumed alcohol on a regular basis, and had negative history
of illicit drug use. Family history was positive for transient ischemic attacks (TIA), myocardial infarction
(MI), and stroke.
Upon presentation to our hospital, he was afebrile with normal vital signs and normal cardiopulmonary
and abdominal examination. Neurological exam was positive for equally diminished lower extremity
deep tendon reflexes and ataxic gait. Computed Tomography (CT) scan of the head was performed
immediately and did not reveal any abnormalities. CT angiogram revealed ostial stenosis of left vertebral
artery associated with a long thrombus in the proximal portion, which extended distally to the level of
the C5 vertebra. Magnetic resonance imaging and magnetic resonance angiogram of the brain revealed
small acute infarcts in the left cerebellum. The patient’s clinical condition deteriorated despite being
placed on anticoagulation therapy with unfractionated heparin. After evaluation by the cardiologist and
neurologist, the patient was taken to the cardiac catheterization unit and a filter-protected
thrombectomy was done and a stent to the origin of the vertebral artery was placed. Patient eventually
improved significantly and was discharged home in good condition.
DISCUSSION: Since the clinical course of vertebral artery disease is still not well understood and
symptoms vary considerably, the utilization of appropriate diagnostic imaging is needed for prompt and
efficient diagnosis. We hereby report a unique case of vertebral artery stenosis revascularization with
complex technical procedure involving a filter thrombectomy and percutaneous angioplasty and
stenting under emergency setting with a favorable result and no side effects. Further evaluation of this
approach is needed to delineate its role in the management of acute vertebral artery thrombosis.
Medications that leave spots. Bullous Pemphigoid and Dipeptidyl Peptidase IV
Inhibitors: A Case Report and Review of Literature.
First Author: Amy H Attaway MD Second Authors: Tracey L Mersfelder PharmD, Sakshi Vaishnav MD,
Joanne K Baker DO
Introduction: Bullous pemphigoid is an autoimmune cutaneous blistering disorder against the
hemidesmosome, which can present as an acute diffuse bullous rash. The etiology for what precipitates
this disease is not entirely clear at this point, although it has been associated with certain medications.
Gliptins are a drug class that was first introduced into the market in 2006 to treat diabetes mellitus type
2. They work by competitively inhibiting the enzyme dipeptidyl peptidase IV (DPP-IV/CD26), which
normally breaks down incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent
insulinotropic polypeptide (GIP), thereby increasing the secretion of insulin and suppressing the release
of glucagon by the pancreas. Since their release into the market they have been linked to several skin
reactions, most serious of which is Steven Johnson syndrome.
Case Presentation: We describe the case of a 70-year-old male with a past medical history of diabetes
type 2 who developed a diffuse bullous rash on his arms, neck, chest, and groin. The patient also
complained of significant urticaria and had evidence of excoriations on extensor surfaces. His laboratory
data was significant only for eosinophilia. He had previously been prescribed sitagliptin 50 mg daily for
at least one year prior to onset of the rash, and this was discontinued prior to presentation at our facility
for fear of Steven Johnson syndrome. The patient under went a skin biopsy that confirmed the diagnosis
of bullous pemphigoid. He was treated with methylprednisolone for three days and was transitioned to
a prednisone taper. The rash significantly improved during this time, and upon discharge he was to
follow up with dermatology clinic to start immunomodulatory therapy.
Discussion: There have been a few reports that have explored the relationship between DPP-IV
inhibitors (gliptins) and bullous pemphigoid, including a case report, a case series, and a report on
sitagliptin associated allergic skin reactions submitted to the Adverse Event Reports System database of
the FDA. According to the Naranjo ADR probability score there is a “possible” cause and effect
relationship for this case.
The enzyme DPP-IV is ubiquitously expressed in almost every organ system, including the skin. Inhibition
of this enzyme has been found to promote eosinophil activation, which is an integral part of blister
formation. Gliptins also disrupt the natural balance of cytokines in the skin, including TGF beta 1, which
may promote imbalances in T helper mediated cell signaling that could precipitate a diffuse cutaneous
eruption of bullous pemphigoid.
CONCLUSION: Our case further demonstrates a link between DPP-IV inhibitors and the development of
bullous pemphigoid. It is important that primary care providers be aware of this reaction so they can
discontinue the offending agent promptly.
Renal Infarct As Initial Presentation of Atherosclerotic Disease
First Author: Adaeze C Okafor, MD Second Author: Michael Yacoub, MD
Introduction: Atherosclerotic disease is the build up of plaques made up of fat, cholesterol, and calcium,
inside the arteries. Over time, plaques can build up and occlude the vessel or break off and cause an
occlusion downstream. The most common clinical presentations of atherosclerosis include angina, ACS,
CVA, and PVD. We are reporting a 48 year old male with no history other than tobacco use, who
presented with a renal infarction as the first manifestation of atherosclerosis.
Case Presentation: Our patient presented with right flank pain for one day which was non-radiating and
associated with nausea, vomiting, chills, and diaphoresis. There was no fever, dysuria, or increased
urinary frequency or urgency. He denied any trauma or interventional vascular procedures. His vital
signs were stable. He was exquisitely tender over the right flank, but there was no abdominal guarding,
rebound tenderness, or hepatosplenomegaly. Urinalysis revealed negative leukocytosis, trace
proteinuria and no hematuria. Testing for HIV, lipid panel, 2D echocardiogram, viral hepatitis, anticardiolipin antibodies, and pANCA were all unremarkable. His serum creatinine was 1.3, and he had a
positive cANCA and elevated CRP. CT scan revealed acute infarction of the mid to lower right kidney,
diffuse occlusive atherosclerotic disease of the abdominal aorta and iliac arteries.
Discussion: Our case is unusual as our patient never had angina, claudication or any neurological
manifestations, and his only risk for atherosclerosis was smoking. He had no history of hypertension,
DM, hypercoagulable states, hyperlipidemia or contributing family history.
Incidental Finding of Severe Hypoxia in an Asymptomatic Patient Caused by
Pulmonary Arteriovenous Malformations
Asad Omar MD
Introduction: Pulmonary arteriovenous malformations (AVMs) are a rare clinical entity, especially when
found in isolation with no underlying etiology. Extensive literature reviews suggest that pulmonary
AVMs are symptomatic in 91% of cases, with dyspnea in 82% and cyanosis in 79% of patients.
Furthermore, 70% are also associated with Osler Weber Rendu Syndrome. We report a case of severe
asymptomatic hypoxia, discovered incidentally on routine pre-operative evaluation, later found to have
isolated multiple large pulmonary AVMs. Workup failed to show any underlying etiology.
Case Report: The patient is a 54 year old female, with a history of COPD and severe aortic valve
insufficiency, diagnosed via an echocardiogram at another facility, referred to cardiovascular surgery at
our hospital. During pre-surgical evaluation, she was found to be hypoxic, with oxygen saturation in the
80%s on 2L of oxygen by nasal cannula and was admitted. Upon admission, her oxygen saturation was at
85% on a non re-breather mask. She denied any symptoms. Physical examination was unremarkable.
Laboratory values showed hemoglobin of 17.3g/L and hematocrit of 48.9%. Chest X-Ray revealed a mass
like density in the right lower lobe (RLL). CT scan of the thorax with contrast was negative for pulmonary
embolus but 4 AVMs in RLL and 2 in right upper lobe were identified. Further questioning and workup
was negative for Osler-Weber-Rendu syndrome or other underlying etiology. Resting echo showed an EF
of 70% and a Bubble Echocardiogram revealed extensive right to left shunting. Bubbles entered from the
pulmonary venous drainage into the left atrium consistent with AVMs. She had a pulmonary angiogram
and AVMs of the RLL were embolizedx2 and an amplatzer vascular occlusion plug was deployedx2. After
embolization, the patient's oxygen saturation was at 95% on 6L of oxygen. A Transesophageal Echo
showed moderate aortic insufficiency and she decided to forego cardiac surgery.
Discussion and Conclusion: Studies show most cases of pulmonary AVMs have an underlying etiology
and are symptomatic in 91% of patients. Our case represents a patient with large asymptomatic
pulmonary AVMs with no underlying etiology. It shows that in patients presenting with hypoxia with no
clear underlying cause, pulmonary AVMs can be considered as a cause and that pulmonary angiogram
and embolization of AVMS is the cornerstone of treatment of pulmonary AVMs.
Eosinophilic Pneumonia, Rare but fatal side effect of Daptomycin: A case
First Author: Jaya S Edukulla, MD Co-authors:Swati Choudhary MD, Alexander Glick MD, Derek DeSouza
Introduction: Daptomycin is a cyclic lipopeptide antibiotic active against Gram-positive bacteria
including Methicillin resistant Staphylococcus aureus (MRSA) and Vancomycin resistant Enterococci
(VRE). Recent case reports have shown that Daptomycin can cause serious respiratory complications
including Eosinophilic pneumonia (EP). EP is characterized by pulmonary infiltrates and increased
numbers of eosinophils in lung tissue or broncho-alveolar lavage (BAL) fluid, with or without increased
level of eosinophils in the peripheral blood. We present a case of EP following the treatment with
Daptomycin for MRSA osteomyelitis.
Case Presentation: 72 year old Caucasian male with history of Diabetes Mellitus type II, Hypertension,
Hyperlipidemia and peripheral vascular disease was admitted for diabetic foot infection. Patient was
started on vancomycin and ceftriaxone. Patient underwent angioplasty with atherectomy of left
popliteal artery to promote healing. Podiatry performed cross-hatching of the wound and cultures
showed gram-positive cocci. MRI Left foot was consistent with early osteomyelitis of great toe. Patient
was discharged on vancomycin and ceftraixone for 6 weeks. Vancomycin was switched to daptomycin
due to worsening renal function. 15 days later patient was readmitted to intensive care unit secondary
to hypoxic respiratory failure. Physical exam revealed bilateral diffuse crackles. Patient was started on
supplemental oxygen. Chest x-ray showed patchy bilateral infiltrates.
Daptomycin was discontinued because of the suspicion of EP. BAL was done which revealed numerous
eosinophils, moderate neutrophils and all bacterial, viral and fungal cultures were negative. High dose
corticosteroid was started, 5 days later hypoxia resolved. Shortly after the steroid taper was completed,
he developed recurrent dyspnea and pulmonary infiltrates. He was restarted on steroids and
autoimmune conditions were ruled out. HRCT showed extensive bilateral parenchymal abnormalities
with patchy ground glass opacities as well as reticulation. Repeat BAL was negative for eosinophilia.
Patient’s EP improved but patient expired secondary to heart failure.
Discussion: EP is an uncommon entity most commonly associated with use of antibiotics and nonsteroidal anti-inflammatory drugs. Pathophysiology involves triggering of immune response due to an
offending agent, leading to eosinophilic chemotaxis and localization into the lung. EP should be
considered in individuals who receive Daptomycin and develop new pulmonary infiltrates. Significant
morbidity and mortality can occur if this condition remains unrecognized and not properly treated in a
timely fashion. Daptomycin toxicity mechanism remains uncertain and further studies are necessary.
Jaurigue, MD
“Don’t Touch My Neck”: A Case of Internal Carotid Artery Dissection
Presenting With Painful Horner’s Syndrome After Chiropractic Manipulation
First Author: Maryconi M Jaurigue, MD; Edmund D Jacob, MD; Darshil Shah, MD, Department of Internal
Medicine, William Beaumont Hospital
Introduction: Chiropractic manipulative therapy (CMT) has been implicated in cases of internal carotid
artery dissection (ICAD), although no causal relationship has been established. Of the patients with
ICAD, 40-60% present with painful isolated Horner’s syndrome.
Case Presentation : A 59 year-old male, with no significant medical history, presented with a two-day
history of occipital and frontal headache and left ptosis. The headache was dull, 6/10 in severity, more
prominent on the left side, and partially relieved by rest. The patient noted going to a chiropractor
three days prior to the onset of symptoms. Physical examination revealed ptosis of the left eye and
anisocoria, with the left pupil measuring approximately 1 mm less than the right pupil, both reactive to
light. The rest of the examination was otherwise unremarkable. Head CT and CTA revealed focal arterial
dissection of the left internal carotid artery, causing severe constriction of the arterial lumen affecting
the petrous segment. The patient was started on IV heparin and therapy was changed to ASA and
clopidogrel. Cerebral angiography and stenting of the affected artery were performed. He completed
three months of antiplatelet therapy with significant improvement of symptoms and no new neurologic
sequelae, with repeat CTA showing no recurrence of dissection.
Discussion: This case illustrates a possible causal relationship between CMT and ICAD. It also further
strengthens the association between isolated Horner’s syndrome and ICAD, and the importance of early
identification and treatment in decreasing the likelihood of ischemic stroke and its complications.
A unique case of non-AL cardiac amyloidosis associated with plasma cell
First Author: Raza Abbas, MD Other authors: Syeda H Batool, MD Nicole Y Marijanovich, MD
Introduction: Cardiac amyloidosis encompasses a spectrum of conditions characterized by deposition of
proteins in the heart musculature. Primary amyloidosis or the AL type cardiac amyloidosis is the most
common one and is often seen in conjunction with multiple myeloma or other plasma cell dyscrasias.
Non-AL types have not been associated with plasma cell proliferation. We present a unique case of nonAL type cardiac amyloidosis in a patient with monoclonal gammopathy.
Case Presentation: A 72 year-old female with a history of diabetes mellitus, hypertension, chronic
kidney disease, and diastolic heart failure presented to our hospital with symptoms of acute respiratory
distress. The night prior to admission, she had woken up with severe shortness of breath and mild
substernal chest discomfort. Physical examination was consistent with classic signs of heart failure,
comprising crackles on lung auscultation and lower extremity edema. An ischemic work up, including
cardiac markers and an electrocardiogram was negative. Four months prior to this admission, the
patient had been given the diagnosis of diastolic heart failure when she had presented with similar
symptoms. Work up at that time had revealed basal septal hypertrophy on echocardiogram and mild to
moderate disease on cardiac catheterization, not amenable to any intervention. A follow up
echocardiogram on this admission indicated that she now had severe hypertrophy with a rapid increase
in wall thickness. As part of her work up, an IgA kappa monoclonal protein was mildly elevated on serum
protein electrophoresis. An endomyocardial biopsy ensued which confirmed a diagnosis of non-AL type
cardiac amyloidosis. The patient’s fluid status was optimized and she was subsequently discharged
home. She continued to follow up with Cardiology and Oncology for further evaluation and
management. A bone marrow biopsy, done two months later, revealed 5-10% plasma cells and a
diagnosis of monoclonal gammopathy of undetermined significance (MGUS) was made.
Discussion: A myriad of disorders has been known to result in increased deposition of amyloid protein in
the heart musculature leading to cardiac amyloidosis. AL type cardiac amyloidosis has commonly been
associated in literature with multiple myeloma. The non-AL types of amyloidosis have either been
reported with genetic mutations in protein structure or found to have no correlations. This is a rare case
of non-AL type cardiac amyloidosis associated with plasma cell proliferation. Since the presentation of
these two disorders concomitantly can change the management altogether, this case signifies the
importance of evaluation for plasma cell dyscrasias, even in patients with non-AL type amyloidosis.
A Case of Pustular Psoriasis
First Author: Sana Syed, MBBS Second Author: Shaheer Zulfiqar, MD Third Author: Manivannan
Veerasamy, MD
INTRODUCTION: Psoriasis is a chronic medical condition with significant morbidity. One of the less
common sub types is Pustular Psoriasis, with an annual incidence of 0.64-1.76 per 1 Million. It is
characterized by extensive erythema of the skin with pustules of variable size coalescing into larger
lesions, mainly present on the trunk, upper and lower extremities. Skin involvement can be variable and
it’s similarity to various other conditions often leads to confusion when making the diagnosis.
PATIENT DESCRIPTION: The patient is a 68 years old woman with medical history of hypertension and
long standing psoriasis well controlled on Methotrexate. Two weeks prior to presentation, she had
symptoms of an upper respiratory tract infection and was started on cephalexin. After starting the
antibiotic, she developed a erythematous pruritic rash, without scales under her breasts which
continued to worsen, with development of a generalized eruption consisting of painful pruritic and
pustular lesions with erythema. The nature and distribution of these lesions were different from her
usual psoriasis flares. She also developed fevers and rigors with the onset of this rash. She was seen by a
dermatologist, had skin biopsy performed and then referred to the hospital. Examination showed
tachypnea, tachycardia and extensive erythema of the skin with pustules of variable size coalescing into
larger lesions, mainly present on the trunk, upper and lower extremities and axillae but sparing the
mucosal surfaces, hands and feet. The lower back had flaccid blisters with erosions. The remainder of
the exam was normal.
HOSPITAL COURSE AND INTERVENTION: The initial treatment was mainly supportive. The patient was
started on intravenous fluids, pain control and Vancomycin for the possible infectious etiology. Local
skin care was done with topical bacitracin, triamcinolone ointment, Vaseline and Xeroform. Finally, skin
biopsy showed intra-epidermal pustular dermatitis with predominant sub-corneal distribution,
consistent with pustular psoriasis. Antibiotic was discontinued. She improved well with the treatment.
CONCLUSION: Pustular psoriasis can lead to life threatening complication including sepsis and
electrolyte abnormalities. Infections particularly upper respiratory infections can cause the flare.
Pustular psoriasis can occur even in patients with other forms of long standing psoriasis e.g plaque
psoriasis, as in our patient. If antibiotic treatment is initiated already, it can be confused with drug
eruption pustulosis.
Aluminum Saftey in End Stage Renal Disease
First Author: Leonid Shamban, DO Second Author: Samira Ahsan MD Third Author: Cathy Saski RD
Introduction: Aluminum toxicity in dialysis patients has been documented since the 1970s and 80s when
Aluminum was used as a phosphorus binder. It was then realized that elevated Aluminum levels was
highly associated with dementia and Osteomalacia in dialysis patients. Aluminum is filtered via the
kidneys and with any insult there is concern for toxicity especially with any Aluminum based
Case Presentation: A 48-year-old African American female with a history of Diabetes Mellitus Type II
who was recently started on dialysis. The patient receives dialysis three time a week. During an routine
evaluation at the center it was noted that the patient’s Aluminum level was 27 mcg/L with a Lab normal
of 10 mcg/L. Aluminum levels are normally checked once a year and this was the patient’s first
evaluation. The patient’s medications were then evaluated, and the patient was told to stop taking her
Sucralfate, an anti-ulcer medication with an Aluminum base. Two months later the patient’s Aluminum
level was rechecked and now it was 43 mcg/L. At that point deferoxamine was considered but was not
administered because the patient did not have any clinical or laboratory signs toxicity: encephalopathy,
worsening anemia, or low parathyroid hormone levels. The patient continued to take Sucralfate 1 gm
four times a day. The patient was again advised on discontinuation. Repeat levels two weeks later
showed decline with 41 mcg/L and then three weeks after was 28 mcg/L.
Discussion: This case illustrates how certain benign medications can be very dangerous in dialysis
patients. There currently no recommendations on proper Sucralfate dosing in End Stage Renal. The
medication is cautioned but still recommened if patients have gastric/duodenal ulcers. Aluminum
toxicity is a rare but can be deadly therefore it is critical that medication composition is evaluated closer
in End Stage Renal Disease.
A Rare Case of Intracystic Papillary Carcinoma of the Breast in a Male
Zaid Kasmikha, DO, Armin Kamyab, MD, Michael Jacobs, MD, Usha Singhi, MD
Introduction: Intracystic papillary carcinoma is a distinctive variant of papillary ductal carcinoma
confined to a dilated cystic space and surrounded by a fibrous capsule. This rare mammary neoplasm
presents as a discrete and solitary mass in a central region of the breast in a postmenopausal woman
and comprises between 0.5% and 2% of all breast cancers. Herein, we report a case of intracystic
papillary carcinoma in the male patient, which has only been reported in a few cases worldwide.
Case Description: A 60 year old Caucasian male presented to an outpatient Internal Medicine clinic with
a complaint of a 1 cm tender and fixed nodule, palpable in the left subareolar region, accompanied by a
clear nipple discharge. The patient exhibited slight skin dimpling but had no nipple retraction, redness of
the breast skin or lymph node enlargement. There is no history of radiation exposure, liver disease, or a
family history of breast cancer in a first degree relative. An ultrasound of the left breast was performed
which revealed a 1 cm round mass in the middle depth suspicious of malignancy. An ultrasound guided
core biopsy was performed which revealed an atypical sclerosing papillary lesion, likely papillary
intracystic carcinoma. The cytology of the nipple discharge was negative for malignant cells but could
not exclude papilloma or other epithelial proliferation. The patient subsequently underwent a left
mastectomy and sentinel lymph node biopsy, which was negative. The papillary tumor was 1.3 x 1 cm of
non-invasive type with a smooth surface and clear margins. Serum tumor markers and BRCA-1 gene
mutations were negative. No additional surgical treatment was needed and the patient was free of
disease after excision.
Discussion: This case illustrates the rare finding of an intracystic papillary carcinoma of the breast in an
elderly Caucasian male and the value of a thorough history and physical along with the necessary follow
up testing. Assessing a patient’s personal and family history is vital, since male breast cancer tends to
occur more frequently when one or more female relatives also had breast cancer. Early recognition is
important since male breast cancer tends to affect the skin and muscles underneath the breast more
quickly than female breast cancer. While breast cancer in males tends to be smaller when found due to
the significantly less amount of breast tissue, it is more likely to have spread past the breast than female
breast cancer. Recognition of these findings is crucial to the institution of appropriate therapy and
prevention of metastasis.
A Clinical Surprise; Severe Myocardial Hypertrophy With Apical Blood Stasis,
Cardioembolic Stroke, and Ventricular Tachycardia
First Author: Timothy R Larsen, DO Ibrahim Sidiqi, MD, Sachin Kumar Amruthlal Jain, MD, Shukri David,
Introduction:Hypertrophic cardiomyopathy (HCM) is a genetic disease effecting the cardiac sarcomere,
60-70% of cases arise from a contractile protein mutation. Patients with HCM are at risk for heart
failure, arrhythmias, and sudden cardiac death. For many patients the clinical course is benign, a small
subset however will develop progressive hypertrophy and ultimately end stage disease.
Case: A 69 year old female presented to the emergency department after receiving a single shock from
her implanted cardioverter defibrillator (ICD). She was aphasic from a prior stroke and only able to
answer yes or no, thus past history was obtained from family. She did indicate chest pain that appeared
to be, non-exertional, intermittent, radiating to her left shoulder, relieved with sublingual nitroglycerin,
and associated with dyspnea. In addition to stroke (presumed cardioembolic), she had a history of an
unknown "heart condition" for which the ICD was implanted in 2006, atrial fibrillation, and
hypertension. Home medications included metoprolol, prilosec, simvastatin, coumadin, and furosemide.
All prescribed by her primary care physician, she had not seen a cardiologist since ICD implantation.
On presentation she was afebrile, blood pressure 130/86 mmHg, pulse 71 beats/minute, and respiratory
rate 20 breaths/minute. Pulmonary exam revealed fine rales in the lung bases, no wheezes or rhonchi.
Cardiovascular exam revealed a grade 2/6 holosystolic murmur over the apex, peripheral pulses were
palpable and equal throughout. Laboratory data revealed normal blood counts, potassium 3.6 mmol/L,
magnesium 1.8 mEq/L, creatinine 1.8 mg/dL, blood urea nitrogen 38 mg/dL, INR 1.4, N-terminal proBNP
173 pg/mL, troponin 0.02 ng/mL (normal 0.00-0.10). EKG revealed ST-segment elevation in leads V3-V6.
Cardiac monitor demonstrated 10-16 beat runs of ventricular tachycardia. Given her chest pain, EKG
findings, and ventricular tachycardia, she was referred for possible coronary intervention.
Coronary angiogram revealed no obstructive atherosclerotic disease. Left ventriculogram revealed
severe mid-cavity obstructive cardiomyopathy with stasis of blood in the apex. Echocardiogram revealed
akinesis of the apex with blood stasis, near obliteration of the mid ventricular cavity, inferior vena cava
dilatation, and moderately depressed left ventricular function. Interrogation of her device confirmed
appropriate electrical therapy for ventricular tachycardia, the prior device interrogation was over 5
years ago.
Discussion: Sudden cardiac death, heart failure, and stroke are the major causes of death in patients
with HCM. In a review of 744 consecutive patients Maron et al identified a mortality rate of 12% over a
mean follow-up of eight years; 51% were sudden, 36% due to heart failure, and 13% from cardioembolic
stroke. In addition to progressive heart failure recurrent strokes, our patient is at risk for micr vascular
ischemic disease, heart block, infective endocarditis, and myocarditis. It is rare in routine medical
practice to identify and treat the terminal phases of these uncommon conditions.
"A diagnosis hidden in a puff of smoke" Pseudobulbar Palsy Secondary to
Stroke in a Patient with Moyamoya Disease
First Author: Inder S Tandon, MD Michael Burton, MD Matthew Holtzman, MD
Introduction: Moyamoya disease is a very rare and potentially lethal condition caused by progressive
occlusions of the cerebral vasculature, the etiology of which is largely unknown. The most common
complications of moyamoya disease are intracranial hemorrhage and stroke, often occurring
sporadically in the absence of other traditional risk factors. We present such a case
Case Report: We present the case of a 38 year old female with a history of hypertension and previous
ischemic stroke with residual left-sided weakness. She presented with a three day history of altered
mentation, dysarthria, weakness, and scotoma. She denied any other neurologic deficits. On
examination, vitals were stable. She was oriented to person and place but not time. She exhibited
marked dysarthria, aphasia, and drooling with inability to manipulate foods. Additionally, she exbihited
a left-sided facial droop and marked emotional lability.
A full metabolic workup including a lipid panel and a hypercoagulability workup was obtained and noted
to be within normal limits. A CT scan of the head was obtained and revealed multiple wedge shaped
hypodensities bilaterally consistent with infarctions, which were confirmed with MRI. CT angiography
revealed profound narrowing and functional occlusion of the right and left internal carotid arteries with
the termini of the carotid arteries being replaced with a diffuse network of collateral circulation.
Additionally, complete occlusion of the M1 and further distal branches of the left MCA were also noted
with reconstitution via collateral circulation. These findings are consistent with a moyamoya pattern.
Given the patient’s radiographic and angiographic findings coupled with the acute constellation of
symptoms consisting of dysarthria, drooling, difficulty chewing and swallowing and emotional lability, a
diagnosis of pseudobulbar palsy secondary to stroke arising from moyamoya disease was made.
Discussion: Moyamoya disease is a progressively occlusive disease of the cerebral vasculature
“moyamoya” derived from Japanese, means “puff of smoke,” a term which characterizes the hazy
appearance of collateral vessels adjacent to stenotic vessels. Pathophysiologically, there is intimal
thickening of the terminal portion of the internal carotid arteries, with varying degrees of involvement
with the cerebral arteries. The exact etiology is unknown, however; there appears to be genetic,
autoimmune, and congenital associations. The prevalence in the US is 0.086 cases per 100,000 people
with a mortality rate of 10% in adults and 4.3% in children. The most common cause of mortality is
intracranial hemorrhage and associated morbidities of stroke and gradual cognitive decline. Given the
rarity of moyamoya disease, it remains a diagnosis worthy of consideration following a negative workup
in patients with stroke of unknown etiology.
Wiemann, MD
Pericardial Cysts: Supporting the Treatment Paradigm
First Author: Charlotte E Wiemann, MD Second Author: Rony Gorges, MD Third Author: Gurbir Singh,
MD Fourth Author: Shukri David, MD Fifth Author: Michael Marshall, MD
Introduction: Pericardial cysts are very rare with an estimated incidence of 1:100,000 and are usually an
incidental finding. Even more rare are pericardial cysts that present with symptoms (25%). The
uncommon nature of this entity has resulted in a lack of clear management guidelines.
Case Presentation: A 37-year-old male presented to the ED with palpitations, left-sided chest pressure
and progressive dysphagia. Physical exam and EKG were completely unremarkable, however, a chest
radiograph did reveal a large mass obscuring the left lower lung field and left heart border. Further
imaging via CT with iodinated contrast demonstrated a large, homogenous, fluid filled anterior
mediastinal mass measuring 15.3 x 9.3 x 5.0 cm arising from the pericardium likely representing a
pericardial cyst. A resting 2D-echocardiogram further supported the diagnosis by demonstrating a large
echo-lucent space anterior to the heart without evidence of tamponade physiology. After evaluation by
cardio-thoracic surgery the patient was determined to be a surgical candidate and subsequently
underwent a left video-assisted thoracoscopic surgery for drainage and removal of his pericardial cyst.
The patient’s symptoms resolved shortly after surgery and he was discharged from the hospital. Surgical
pathology and cytology confirmed the cyst was indeed of pericardial origin.
Discussion: Pericardial cysts develop as a result of disruption in the embryologic formation of the
pericardial sac. This occurs via failure of mesenchymal pericardial lacunae to fuse. They are benign
lesions most often located at the cardiophrenic angle (right 70%, left 22%) and rarely in the anterior or
posterior mediastinum (8%). Pericardial cysts occur equally in men and women and are usually
discovered in the 3rd-4th decade of life. Common symptoms include chest pain, dyspnea, cough, and
palpitations. Our case, like most reported cases, resulted in surgical intervention. It is generally accepted
that serial imaging can be used to conservatively manage asymptomatic lesions but large or
symptomatic cysts require intervention. Although accepted in practice, there is a clear lack of evidence
based treatment guidelines.
A Rare Case Of Male Breast Sarcoma
First Author: Tezo Anto Karedan, MD Ioana Moarariu, MD Second Author: Madan Arora, MD Rajitha
Valsan, MD David Wiese, MD William Naill, MD Last Author: Sukumal Saha, MD
Introduction: Male breast cancer is rare, accounting for less than 1% of all cancers in men. Specifics
related to male breast cancer have been largely inferred from female breast cancer. Breast sarcomas are
rare in women; extrapolating that data to men, they constitute less than 0.001% (1/100,000) of all male
Case Presentation: A 60-year-old male presented in 2005 with a six-month history of a painless right
breast lump. A breast mass extending into the pectoral muscle, with no distant disease on work-up, was
identified. Initially diagnosed as adenocarcinoma by fine needle aspiration cytology, it failed to respond
to neoadjuvant chemotherapy and radiation. An incisional biopsy revealed a pleomorphic sarcoma. The
patient responded to a sarcoma-directed neoadjuvant chemotherapeutic regimen and had right radical
mastectomy followed by adjuvant chemotherapy.
The disease relapsed after two years with a solitary left pulmonary nodule. Wedge resection confirmed
metastatic pleomorphic sarcoma. Two years later the patient had disease recurrence in the left breast
and right lung. He received chemotherapy and left radical mastectomy. With extensive pulmonary
disease progression, despite aggressive therapy, the patient opted against further treatment. One and a
half years later, and seven years after initial diagnosis, he remains alive without active treatment.
Conclusion: Breast sarcomas account for less than 0.1% of all breast cancers. This patient had
recurrence despite radical mastectomy and systemic chemotherapy for what appeared to be local
disease. Despite of the aggressive nature of the tumor and multiple metastases our patient has survived
more than seven years after first diagnosis.
Myelodysplastic Syndrome, Constipation, and Neuralgia…Adult Plumbism?
First Author: George T Dunham, MD
Introduction: Lead is a heavy metal and neurotoxin causing pathology in many organ systems, but is
rarely encountered in adults. Common signs of plumbism include anemia, neuropathy, and
neuropsychiatric effects, but vary widely between cases. Lead is an environmental contaminant found
in soil, water, and air secondary most commonly to leaded gasoline prior to 1976, soil adulterating from
battery manufacturing, and leaded paint. Ammunition contains large amounts of lead, but is an
exceedingly rare etiology.
Case Presentation: 34 year old African American male presented with 3 weeks of progressive neuralgia
of all extremities, parasthesia, constipation, abdominal pain, weakness, and fatigue. Patient’s medical
history revealed a gun shot wound to the left distal femur in 1993. The patient’s physical exam revealed
conjunctival pallor, parasthesia of all extremities, abdominal tenderness, and decreased ROM of the left
Initial laboratory studies showed: hemoglobin: 6.6g/dL and MCV: 82.3fL. Bone marrow biopsy revealed
60% cellular marrow with erythroid dysplasia and 23% ringed sideroblasts consistent with
myelodysplastic syndrome. Radiograph of the left knee revealed multiple metallic fragments with
lobulated calcifications. Further studies revealed a lead level >200 mcg/dL and zinc
protoporphyrin:heme ratio of >600umol/mol.
The patient was treated with IV edentate calcium disodium (EDTA) and Succimer (2, 3
dimercaptosuccinic acid). Follow up lead level was 121mcg/dL. The patient suffered from refractory
anemia and elevated lead levels despite 3 round of EDTA and Succimer chelation over the course of the
next 6 weeks. Surgical removal and pathology of the 13.9×6.2×3.7cm pseudotumor showed foreign
body giant cell reaction, granulomatous inflammation, and histological evidence of lead within the
periosteum. The lead level five days post-operatively was 24.6mcg/dL. The patient described resolution
of neuralgia, constipation, and parasthesia as lead levels trended down.
Conclusion: Lead poisoning is a uniformly lethal toxicity if untreated and a rare sequela of retained
bullets. It has classical and non-classical symptoms for which physicians should maintain a high index of
suspicion as prompt treatment is crucial to prevent adverse and even fatal outcomes. It is felt that the
critically and persistently elevated lead levels in this patient were the result of the acidic, enzymatic
activity of the periosteum where the fragments were embedded. The dramatic resolution of lead levels
post-operatively confirm that the source of lead were the retained fragments. This case is unique
because the fragments were located outside a synovial space. The literature does report retained
fragments as a rare etiology, but all reviewed cases reported in the past 60 years describe fragments
located in a synovial space. Clinicians practicing in urban environments with an increasing amount of
gunshot victims and subsequently retained fragments should be aware of this potentially fatal sequela
and should screen patients with retained fragments.
Antalan, MD
Rituximab-Induced Subacute Tumor Lysis Syndrome in a Patient with Chronic
Lymphocytic Leukemia
First Author: Tessa Marcelle Antalan, MD Second Author: Maureen Muke, MD Last Author: Radhika
Kakarala, MD
Introduction: Tumor lysis syndrome (TLS) is a serious clinical consequence of accelerated cell death and
is seen more commonly after chemotherapy initiation than after immunotherapy, leading to potentially
life-threatening complications. Rituximab is an immunotherapy agent usually given in combination with
fludarabine to treat chronic lymphocytic leukemia (CLL). We present a rare case of subacute tumor lysis
syndrome in a patient with CLL who presented ten days after a single dose of rituximab monotherapy; in
fact, our literature search revealed a single similar case.
Case Presentation: A 59 year-old Caucasian male, with a past medical history of CLL and stable white
blood cell counts for two years, chronic kidney disease with baseline creatinine of 2.0 mg/dL,
cerebrovascular accident and hypertension, was admitted for altered mental status. He was recently
noted to have a large right supraclavicular lymph node; outpatient blood work revealed a WBC count of
96,000/mm3. Twelve days prior to presentation, he was started on outpatient rituximab 700 mg as
monotherapy at a different institution. He was pre-medicated only with diphenhydramine and
dexamethasone. One week after treatment, he began to have nausea, vomiting, and w