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New Jersey Chapter American College of Physicians Resident New Jersey Chapter American College of Physicians Resident Abstract Competition 2018 Submissions Category Name Additional Authors Program Abstract Title Abstract Clinical Vignette Ankit Bansal Ankit Bansal MD, Robert Atlanticare Rare Case of A 62‐year‐old male IV drug abuser with hepatitis C and diabetes presented to the emergency Lyman MS IV, Saraswati Regional Necrotizing department with progressively worsening right forearm pain and swelling for two days after injecting Racherla MD Medical Myositis leading to heroin. Vitals included temperature 98.8°F and heart rate 107 bmp. Physical examination showed Center Thoracic and erythematous skin with surrounding edema and abscess formation of the right biceps extending into (Dominik Abdominal the axilla, and tenderness to palpation of the right upper extremity (RUE). Labs were white blood cell Zampino) Compartment count 16.1 x103/uL with bands 26%, hemoglobin 12.4 g/dL, platelets 89 x103/uL and blood lactate 2.98 Syndrome mmol/L. Patient was admitted to telemetry for sepsis secondary to right arm cellulitis and abscess. Bedside incision and drainage was performed. Blood and wound cultures were drawn and patient was started on Vancomycin and Levofloxacin. On the third day of admission, patient became febrile, obtunded and had signs of systemic toxicity. Labs showed a worsening leukocytosis and lactic acidosis. CT RUE was consistent with complex fluid collection and with extensive gas tracking encircling the entire length of the right biceps brachii muscle. Surgical debridement was performed twice over the next few days. Blood cultures grew corynbacterium and coagulase negative staphylococcus; wound culture grew coagulase negative staphylococcus. Levofloxacin was switched to Aztreonam. Patient continued to deteriorate, went into renal failure, and was transferred to the ICU where he was started on vasopressors and bicarbonate drip. MRI RUE revealed severe myositis involving the biceps brachii, coracobrachialis and pectoralis minor muscles. Patient was transferred to another hospital for possible amputation of RUE. The patient’s condition continued to decline. Following extensive workup, patient was diagnosed with chest and abdominal compartment syndrome requiring decompressive exploratory laparotomy. Given the severity of his illness and poor prognosis, his family decided to proceed with comfort care. Patient expired few hours later. Necrotizing fasciitis and myositis (NF&M) is clinically indistinguishable from soft tissue infections (STI) because of its rarity and lack of classic symptoms. In one report, only 21 cases of necrotizing myositis were documented between 1900‐1985. While, only 4 cases out of 20,000 autopsies were established in a second report. In our patient, characteristic signs and symptoms initially led us to the diagnosis of cellulitis. However, one must always consider NF&M in the differential diagnosis when presented with uncharacteristic symptoms such as escalating muscle pain, skin changes, and systemic toxicity. An MRI of the affected extremity must be obtained for an early diagnosis. An early debridement along with broad‐spectrum antibiotic coverage is the key to a better outcome. Category Name Additional Authors Program Abstract Title Abstract Clinical Vignette Amulya Dakka Muhammad Ahad Nabil Atlanticare A Case of Clinically Vancomycin is a glycopeptide antibiotic used to treat infections mainly caused by MRSA. Common side MD, Syed Jaleel MD Regional Diagnosed effects include nausea, abdominal pain, hypotension and chills. Rare reported adverse effects are Medical Vancomycin‐ Stevens‐Johnson syndrome, Red man syndrome and vasculitis. Thrombocytopenia is a rare side‐effect Center Induced with only a few reported cases. It can manifest as petechiae and uncommonly as a life‐threatening (Dominik Thrombocytopenia bleed. Zampino) Our patient was a 55‐year‐old male who presented from a rehabilitation facility for tachycardia. He recently was discharged from the hospital after being treated for motor vehicle accident. Chest X‐Ray on admission showed right lower lobe opacity. Due to his recent hospitalization, there was a concern for healthcare associated pneumonia and he was started on IV Vancomycin and Cefepime. On the day of admission, his platelet count was 276,000. After three doses of Vancomycin, his platelet count started to decrease while all other cell lineages remained intact. Over the next 4 days, his platelets were down to 56,000. Vancomycin was held at that time due to high suspicion of drug‐induced thrombocytopenia and within 48 hours of its discontinuation, the platelet count started increasing. All other causes of thrombocytopenia were ruled out. He was on Rivaroxaban for atrial fibrillation hence did not need heparin for DVT prophylaxis. Pantoprazole has also been associated with decrease in platelet numbers but was never held as the patient has been chronically taking it at home. Rarely Cefepime has been linked to thrombocytopenia in literature but it was held on the sixth day of admission, after the platelets had already begun to increase. A few facilities have the capability to test for antibodies against Vancomycin but we were unable to get access to such an amenity hence the diagnosis of Vancomycin‐induced thrombocytopenia (VIT) was made clinically and by exclusion. On the day of discharge, 5 days after discontinuation of Vancomycin, his platelet count was 213,000. Severe thrombocytopenia is a rare but potentially life‐threatening complication of Vancomycin therapy. The etiology is considered to be immunologically mediated as suggested by the presence of specific drug dependent IgG and IgM antiplatelet antibodies in most patients however other mechanisms have also been suggested in studies. Early diagnosis may be made in specialist centers through detection of antibodies however these tests are not standardized and currently inaccessible to most places. Hence any abrupt decline in platelet count should prompt investigation and clinical suspicion should be high. Our patient had no other known risk factors for the development of rapid thrombocytopenia. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 7) between thrombocytopenia and vancomycin therapy. Platelets usually return to pre‐treatment values after discontinuation of the drug and the median time required ranges from 4 to 17 days. Category Name Additional Authors Program Abstract Title Abstract Clinical Vignette Ahmed Elshazly A. Elshazly, S. Huma, J. Atlanticare Iatrogenic Bilateral Inferior vena cava filter (IVCF) is widely used for patients with deep vein thrombosis (DVT) and Maalouf, O. Shahateet Regional Renal Vein pulmonary embolism (PE) who are not candidates for anticoagulation which is the preferred Medical Thrombosis treatment. Center (Dominik The application of IVC filters seems to have decreased over the years. Many complications are Zampino) associated with IVCF including thrombosis and filter migration into the right atrium, pulmonary artery, right gonadal vein and lumbar veins. We present a case of anuric acute renal failure due to bilateral renal vein thrombosis from IVCF migration. 68 years old male with a past medical history of DVT, PE with IVCF 5 years ago, diabetes mellitus, hypertension, obstructive sleep apnea presented to the emergency department with severe back pain. The patient started to have severe lower back, present throughout the day, constant, nonradiating and associated with nausea and vomiting. The patient was noted to have anuria and worsening azotemia. The patient was started on hemodialysis. Further workup revealed extensive bilateral proximal DVT on Doppler ultrasound. Computerized axial tomography (CT) abdomen showed features of bilateral renal vein thrombosis in the context of IVCF transverse migration occluding both renal veins. Heparin drip was started. The patient underwent an angiogram with thrombectomy. His kidney function and urine output started to improve and the patient was taken off dialysis. Discussion: IVCF migration is a rare complication and was reported in a minimal number of case reports. A previous case report showed filter migrated to a suprarenal position inside IVC causing bilateral renal vein thrombosis causing acute renal failure. Our case showed migration of IVCF into a transverse position within the renal veins bilaterally resulting in the renal shutdown. Category Name Additional Authors Program Abstract Title Abstract Quality Ahmed Elshazly A. Elshazly, C. Atlanticare Quality Introduction: Cocaine abuse causes various complications including hypertension (HTN), acute Improvement/Patient Vandenburg Regional improvement coronary syndrome, Myocardial infarction (MI), stroke, and even death. Safety Medical study to decrease The use of β‐Blockers (BB) with cocaine has been controversial. BB can cause unopposed α‐receptor Center complications stimulation, resulting in HTN and coronary vasospasm (CVS). According to ACC/AHA guidelines: β‐ (Dominik associated with blockers should not be administered to patients with ST‐segment Elevation Myocardial Infarction Zampino) the use of beta (STEMI) precipitated by cocaine use because of the risk of exacerbating CVS. blocker with cocaine. Methodology: 5123 patients who presented to AtlanticCare Regional Hospital between 2012‐2016 and had Urine Drug Screen positive for Cocaine (UDS‐C) were identified by retrospective chart review. Inclusion Criteria, older than 18 years, UDS‐C. The Quality Improvement Study (QI) got Institutional review
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