PROCEEDINGS

Proceedings from the 2011 Annual Meeting of the American College of Physicians, Wisconsin Chapter

The Wisconsin Chapter of the American College of Physicians held its annual meeting in evaluate the temporal relationship between Wisconsin Dells, September 9-11, 2011. Internal medicine residents from each of Wisconsin’s 5 onset of atopic dermatitis (AD) and EE residency programs presented their research and/or unusual clinical experiences via posters diagnosis. and vignettes. Methods: A retrospective cohort study was conducted in a population-based cohort. PRESENTED POSTERS ger length of hospitalization (OR, 0.72, Esophageal biopsy reports from 1995-

Effect of Hyperglycemia on Outcomes 95% CI, 0.54-0.96, P = 0.03). Forty-one 1997 and 2005-2007 were screened using in Acute Exacerbations of Chronic patients (19%) were readmitted to the SNOMED (Systematized Nomenclature Obstructive Pulmonary Disease hospital within 30 days of discharge from of Medicine) to identify patients with Narendranath Epperla, MD, Yusuf Kasirye, index hospitalization. Adjusting for previ- pathologic confirmed or suspected EE. MD, Melissa Simpson, PhD, Hong Liang, PhD, ous covariates and length of hospitalization, Histopathology reports in which EE could Chaitanya Mamillapalli, MD, Steven Yale, MD; BG was not associated with 30-day hospital not be excluded and those with features sug- Departments of Internal Medicine, Biostatistics, readmission (OR, 0.82, 95% CI, 0.54-1.22, and Clinical Research and Marshfield Clinic gestive of EE were reviewed. Cases of esoph- Research Foundation; Marshfield Clinic, P = 0.32). Nine patients (4%) died within agitis due to chemicals, drugs, infections, Marshfield, Wis 90 days of their index hospitalization. inflammation, and structural abnormalities Adjusting for previous covariates and read- Background: Hyperglycemia is associated (tumors, strictures, ulcers) were excluded. mission, decreased BG was associated with with adverse health outcomes independent A single pathologist blinded to clinical, increased odds of 90-day all-cause mortality of its associated metabolic disease states. endoscopic features, and histopathology

(OR, 0.30, 95% CI, 0.11-0.86, P = 0.02). However, little evidence exists concerning diagnosis reviewed 373 tissue specimens. hyperglycemia and outcomes associated Conclusion: Decreased BG levels were asso- Medical records of confirmed EE cases were with acute exacerbations of chronic obstruc- ciated with a longer hospitalization and reviewed to determine associated atopic tive pulmonary disease (AECOPD). This 90-day all-cause mortality, suggesting that dermatitis based on American Academy of study examined blood glucose (BG) during BG during hospitalization may be indicative Dermatology (AAD) criteria, clinical pre- AECOPD hospitalization and clinical out- of overall health and therefore may be a use- sentation, macroscopic findings on endos- comes. We hypothesized that increased BG ful prognostic tool. Blood glucose response copy, and site of biopsy. is associated with worse clinical outcomes. (or lack thereof) in light of hyperglycemic Results: Twenty-seven cases of EE were agents (96% of cohort received corticoste- Methods: We retrospectively studied a cohort positively confirmed: 20 adults and 7 chil- roids during hospitalization) may be a proxy of 215 hospitalized patients (40 to 80 years dren. Median age at diagnosis was 32.1 for a patient’s overall physiological status. of age) with physician-validated AECOPD years. Though 9 patients had some features from January 1, 2004 to December 31, of AD, none met all the major criteria set Eosinophilic Esophagitis: An Escalating 2008. Inclusion criteria for this study were by AAD. There was a significant increase Epidemic? in the incidence rates of EE in the study a diagnosis of AECOPD at admission and Rajesh B Kethireddy, MD, Camille Torbey, MD, discharge, and BG obtained within 6 hours Jeffrey Resnick, MD; Departments of Internal population from 1995-1997 compared to of hospital presentation. Regression analyses Medicine-Pediatrics, Gastroenterology, and 2005-2007 (2.76 vs 13.6 cases per 100,000 accounting for repeated BG measurements Pathology; Marshfield Clinic, Marshfield, Wis person years). Similarly increased incidence during hospitalization were performed to Background: Eosinophilic Esophagitis (EE) rates were observed in both female (1.91 vs estimate the odds ratio (OR) for daily mean is a relatively “new” clinicopathological 11.4 cases per 100,000 person years) and BG and length of hospitalization, hospital entity characterized by chronic esophagitis male (4.37 vs 18.2 cases per 100,000 person readmission, and 90-day all-cause mortality. and dense eosinophilia of the esophageal years) populations. Results: Mean length of hospitalization mucosa. We sought to determine the inci- Conclusions: Given the stability of demo- was 3 days. Adjusting for age and diabe- dence of EE, observe the incidence trends graphic conditions and health care access, tes, decreased BG was associated with lon- between 1995-1997 and 2005-2007, and our study demonstrates an increase in

72 WMJ • APRIL 2012 incidence of EE from 1995 to 2007 in a mean change in Ha1c after approximately critical decision points in patient care, and population-based cohort that cannot be 6 months (n=44) was -1.32±1.66 with doctor-patient communication. attributed to misclassification or misdiag- a P value of <0.001 (95% CI, -1.82 to Conclusions: Nearly 70% of house staff nosis. There was no significant association -0.81); mean change in BMI at 6 months identified at least 1 time in the preceding between atopic dermatitis and EE. These was 0.67±2.42 (P = 0.082) and 1.55±5.39 2 weeks that they wanted to exceed current findings suggest that EE may be more com- (P = 0.021) at the latest date. duty hours. The majority involved provid- mon than previously realized. Identifying Conclusion: U-500 may improve glycemic ing continuity for an acutely ill patient; factors that contribute to this increased risk control, both in the short term and long however, the doctor-patient relationship, should be subject to further investigations. term for those patients in whom glycemic humanistic attention to patients, and control is not achieved with U-100 insulin. workload also were commonly cited. We Long-term Glycemic Control in There does appear to be a small increase in conclude that after July 1, situations will Diabetes Mellitus Patients Started on BMI in the long term. One needs to take routinely arise during which house staff U-500 Regular Insulin this into account when deciding whether will want to stay beyond duty hours, and Rachel McKenney, MD, Mary Frohnauer, MD, Jacob Gundrum, MS; Gundersen Lutheran or not to use U-500. However, this alone this may occur more frequently than antici- Medical Foundation, La Crosse, Wis should not deter a clinician from consider- pated by the ACGME. ing the use of U-500. Background: Glycemic control in types Resident-Driven Quality Improvement 1 and 2 diabetes mellitus has become Working Beyond the Duty Hour Rules Pinky Patel, Karrie Martin, Zouyan Lu; Medical more challenging with the rising obesity Sarah J. Nickoloff, Kathlyn E. Fletcher; Medical College of Wisconsin, Milwaukee, Wis epidemic. In patients who require insu- College of Wisconsin, Milwaukee, Wis Background: There are more than 51,000 lin doses exceeding 200 units/day, using Background: The Accreditation Council for deaths in the United States each year from U-100 regular insulin may not provide Graduate Medical Education (ACGME) colorectal cancer (CRC) and more than adequate glycemic control because of either recently announced new guidelines that 500,000 patients receiving treatment for poorly absorbed subcutaneous depositions will allow occasional exceptions to the duty end-stage renal disease. Early diagnosis or unreliable absorption patterns. hour rules in very limited circumstances. and prevention of both CRC and chronic Methods: This study’s purpose was to test This study assessed the frequency and cir- kidney disease (CKD) leads to better out- the hypothesis that switching from U-100 cumstances in which house staff might use comes for patients, making these optimal regular insulin to U-500 regular insulin these exceptions. areas of concentration for quality improve- improves long-term glycemic control in Methods: We conducted a cross-sectional ment (QI) initiatives. Using the Wisconsin diabetic patients who have not attained gly- survey study of internal medicine house Collaborative for Healthcare Quality cemic control. A retrospective review was staff at a single academic tertiary care hospi- (WCHQ) as a guide for the development conducted for these patients with U-500 tal. The anonymous survey asked about the and measurement of residents’ QI interven- begin dates between January 2005 and 2 prior weeks of ward service and whether tions, the Internal Medicine residency pro- December 2010. participants would have used the antici- gram at the Medical College of Wisconsin The primary measure of long-term gly- pated exceptions, if allowed. Participants (MCW) formulated academic, year-long cemic control is a long-term reduction in also were asked to provide brief descrip- projects to improve outcomes in both CRC hemoglobin A1C (Ha1c). This is defined tions of situations. screening and health markers in CKD. at a time point greater than 8 months Results: Fifty-nine percent of the surveys Methods: For the CRC project, chart post U-500 initiation and ending either were returned. Interns and residents each review of clinic patients identified those when the patient discontinued the use of accounted for 50% of the total. Sixty- appropriate for a targeted QI intervention. U-500 insulin or at the latest available date. nine percent indicated they had wanted Different clinic sites implemented strate- Secondary endpoints studied included to stay longer than current duty hour gies for their specific populations and resi- change in body mass index (BMI) after rules allowed. Of those, 55% would have dents’ interventions, including reminder initiation of U-500 insulin and change in broken the 24 + 6 hour rule; 33%, the letters and patient information pamphlets 6-month Ha1c (collected between 4 and 8 10-hour rule; and 12%, the 80-hour rule. on the importance of CRC screening. months post U-500 initiation). Continuity for an unstable patient was the Chart review also was performed to iden- Results: The mean change in Ha1c for most common reason cited for wanting to tify patients with at least Stage III CKD. long-term analysis (n=68) was -1.11±1.95 stay. Humanistic attention for the family or Interventions included frequent follow- with P value of <0.001 (95% CI: -1.58 patient and educational opportunities also up for blood pressure (BP) monitoring, to -0.64). The mean long-term follow-up were cited frequently. Descriptions of these increased low-density lipoprotein (LDL) was 35.78±22.62 months with minimum situations illustrated several themes, includ- control, and increased testing for protein- of 9.17 and maximum of 93.99. The ing concerns for workload, patient acuity, uria. Changes to the electronic medical

VOLUME 111 • NO. 2 73 record also were introduced to facilitate factor β1-induced phospho-Smad2/3 post-operative histopathology. Previous appropriate interventions for patients with nuclear translocation through activation asbestos exposure is reported in 30% to CKD. Outcomes for CRC screening and of the cyclic guanosine monophosphate 40% of reported cases. BP/LDL goals in CKD patients were mea- (cGMP)/protein kinase G (PKG) pathway Case: A 40-year-old African-American man sured before and after the interventions. in cardiac fibroblasts. Previous study also with a past medical history of hyperten- Results: Initial data from the 2009-2010 demonstrated that in cardiac fibroblast, sion and hyperlipidemia presented with left academic year QI project showed that resi- EPA and DHA increase cGMP levels by testicular swelling and dull aching pain of dents’ comfort using QI measurement to increasing phospho-eNOS and eNOS 4 months. He had generalized fatigue and improve their clinical skill increased from protein levels and nitric oxide production. unintentional weight loss of 20 pounds in 52% to 85% after the educational interven- Caveolin is the principal structural protein the last 4 months. He denied any trauma tion. For the CRC project, evaluation by in caveolae, which interacts with endothe- to his scrotal area, history of asbestos expo- remaining residents 1 year post-interven- lial NOS (eNOS) and leads to eNOS inhi- sure, or family history of cancer. bition. Therefore, we tested the hypoth- tion showed increased CRC screening rates On physical examination, he appeared well esis that EPA and DHA decrease caveolin across all clinic sites. This includes colonos- with stable vital signs. There was no pal- expression in cardiac fibroblasts. copies and other CRC screening modali- pable lymphadenopathy. Lung and cardiac ties. Less data is available for the ongoing Methods/Results: Confluent cultures of adult examinations were unremarkable. There CKD project. Mid-intervention review mouse cardiac fibroblasts in 6-cm collagen- was no gynecomastia. The abdomen was reveals that blood pressure and cholesterol coated plates were incubated in the pres- nontender, and the liver and spleen were control have improved. ence or absence of the indicated control, not palpable. Left hemiscrotum was mark- Discussion: Overall, residents have DHA or EPA for 24 hours. Western Blot edly enlarged and firm, nontender, and responded positively to the program and analysis was carried out to determine pro- without discrete mass. The right scrotum have been enthusiastic about implementing tein levels of caveolin and glyceraldehyde- was normal in size without tenderness or the interventions. For both QI projects, res- 3-phosphate dehydrogenase (GAPDH). indurations, and he exhibited no extrem- ident education on quality improvement as GAPDH was used as the internal control. ity edema. Hemogram, liver, and renal well as on the specific clinical disease being Compared with control, DHA (10 mM) function tests and testicular tumor mark- targeted was integral to the program’s suc- and EPA (10 mM) significantly reduced ers were normal. Computed tomography cess. The CRC QI project clearly improved caveolin/GAPDH ratio in cardiac fibro- (CT) study showed partially visualized left screening rates. Initially, it appears that resi- blasts (72% and 65% reduction, respec- testicular mass and hydrocele without ret- dents are identifying and treating chronic tively P < 0.05) roperitoneal, intra-abdominal pelvic lapa- kidney disease more appropriately. Conclusions: DHA and EPA decrease caveo- roscopy. The remainder of the chest, abdo- lin expression in cardiac fibroblasts. This men, and pelvis were normal. Following a Omega-3 Polyunsaturated Fatty study suggests that EPA and DHA increase diagnosis of left hydrocele, hydrocelectomy Acids Decrease Caveolin Expression intracellular levels of eNOS by decreas- showed a nodular swelling along the testis. in Cardiac Fibroblasts: One Possible ing caveolin expression in cardiac fibro- Histopathology and immunohistochemi- Mechanism of Fish Oil’s Cardiac blasts. Future study is warranted to exam- cal report from the paratesticular mass and Benefits ine whether over-expression of caveolin in hydrocele sac was signed out as papillary Dajun Wang, Aurora Health Care Internal cardiac fibroblast attenuate the EPA- and mesothelia lesion that showed microscopic Medicine Residency Program; Aurora Sinai DHA-induced eNOS activation. early invasion. After the histopathology, Medical Center, Milwaukee, Wis definitive treatment with left orchiec- Background: Heart failure is the leading DISPLAYED POSTERS tomy and hemiscrotectomy was done. The reason for hospital admissions and is the Testicular Mesothelioma? patient subsequently was treated with adju- most costly Medicare expenditure. About Habtamu Belete, Aurora Health Care Internal vant chemotherapy with 2 cycles of Alimta half of heart failure cases are due to dia- Medicine Residency Program; Aurora Sinai and cisplatin. Due to his deteriorating cre- stolic dysfunction. One of the main causes Medical Center, Milwaukee, Wis atinine clearance, cisplatin was switched to of diastolic dysfunction is cardiac fibrosis. Introduction: Malignant mesothelioma of carboplatin. Twenty months after diagno- Previous study demonstrated that Omega-3 the tunica vaginalis testis is an aggressive sis, the patient was free of metastasis. polyunsaturated fatty acids (ω-3 PUFAs, and rare neoplasm, representing less than Conclusion: Our patient had an unusual eicosapentaenoic acid [EPA], and docosa- 5% of all malignant mesothelioma. There neoplasm, mesothelioma of tunica vaginalis hexaenoic acid [DHA]) prevent overload- are fewer than 200 cases reported to date. testis primarily involving the testes. Because induced cardiac fibrosis and cardiac dys- It presents as a hydrocele or an intrascrotal of this clinical scenario’s rarity, treatment function by blocking transforming growth mass, and most diagnoses are made from recommendations are not standardized.

74 WMJ • APRIL 2012 Applying the principles derived from expe- inflammatory skin reaction commonly seen cervical flexion, bilateral lower extremity rience with the treatment of mesothelioma in patients undergoing chemotherapy for weakness, and central visual field defect of the lung and from limited experience hematologic malignancies. It also has been of the left eye. Her laboratory evaluation with the management of testicular meso- reported in healthy patients, patients with revealed leukocytosis, antinuclear antibody thelioma, we can devise an adjuvant che- solid malignancies, infections, and in asso- negative, rheumatoid factor positive, and motherapy regimen and follow-up modal- ciation with certain medications. The erup- elevated serum antistreptolysin-O titer and ity that may offer good long-term survival. tions are often seen in neutropenic patients C-reactive protein. Brain magnetic reso- We also recommend post-hydrocelectomy presenting with fever. It is characterized by nance imaging (MRI) showed new areas of histopathological analysis. the sudden onset of erythematous papules supratentorial white matter signal intensi- and plaques that can affect the trunk, arms, ties and bilateral optic nerve enhancement. Neutrophilic Eccrine Hidradentis legs, and face including the periorbital CSF findings were significant for high in a Patient with Myelodysplastic region. Lesions are typically asymptomatic opening pressure, lymphocytic pleocyto- Syndrome Receiving G-CSF but can be tender and pruritic. A biopsy is sis, low glucose/high protein, but negative Jason R. Darrah, MD, Rachel M. Hawker, required for diagnosis, and histology classi- oligoclonal bands. As the hospital course MD, FACP; Gundersen Lutheran Medical cally reveals neutrophilic infiltration of the Foundation, La Crosse, Wis progressed, the only other significant labo- eccrine glands with accompanying necrosis. ratory findings were the positive IgG and Introduction: Skin rashes are a common and The pathophysiology is not understood IgM Mycoplasma serologies. Given the frequently nonspecific finding with varying entirely but thought to be due to the direct patient’s improvement with steroids, MRI clinical significance. They are often a mani- toxic effect of the offending agent in the findings, and the otherwise negative infec- festation of an underlying process such as sweat glands. Another theory is that NEH tious workup, she was given the working infection, autoimmunity, malignancy, or is part of the spectrum of neutrophilic der- diagnosis of ADEM. A course of systemic medication reaction. For many clinicians, matoses. NEH is self-limiting and resolves corticosteroids, azithromycin, and cipro- these findings pose a diagnostic challenge spontaneously within 1 to 2 weeks without floxacin were completed, and the patient and it may be difficult to determine the any long-term sequelae. Steroids, nonste- made a full recovery. exact etiology. riodal anti-inflammatory drugs (NSAIDs), Discussion: ADEM typically presents with Case: A 54-year-old man with a history of and antibiotics have been used for symptom an acute onset of focal neurological signs myelodysplastic syndrome was admitted control and to decrease duration. Dapsone for fever. On admission, his white blood also has been suggested for prevention of within days to weeks of an initial nonspe- cell (WBC) count was 1.25 K/uL with an recurrent NEH. cific viral illness or vaccination. It usually absolute neutrophil count (ANC) of 0.490 follows a monophasic course, and this K/uL. In addition to fever, he complained Not Just Another Viral Syndrome allows ADEM to be differentiated from of right upper quadrant pain. Imaging was Sana Gafoor, Dai Takahashi, Kurt Pfeifer; multiple sclerosis (MS). However, recently Medical College of Wisconsin, Milwaukee, Wis negative for acute abdominal pathology. reported adult cases have demonstrated However, he was started on ertapenem Introduction: Acute disseminated encepha- multiphasic presentations; consequently for a suspected intra-abdominal infection. lomyelitis (ADEM) is a disorder charac- there has been increased reliance on MRI Over the course of 3 days his abdominal terized by a monophasic inflammatory for diagnosis. The radiographic patterns pain improved but his low-grade fever per- demyelination of the central nervous sys- generally are multifocal asymmetric lesions sisted. On day 4, he spiked a fever of 40°C, tem (CNS). Most cases have been identi- that mainly involve the supratentorial and his ANC dropped to 0.08. As a result, fied in children and usually follow one white matter. Key differentiating factors he was given granulocyte colony stimulat- of the exanthematous diseases, but it also between ADEM and MS are atypical clini- ing tactor (G-CSF). Due to continued fever may present with similar clinical features in cal symptoms of MS, absence of oligoclo- and dropping ANC, on hospital day 6, he adult patients. nal bands in CSF, and eventual gray mat- was given another dose of G-CSF. That Case: A 23-year-old woman with no sig- ter involvement. Successful management same day, he was found to have developed nificant past medical problems presented strategies include corticosteroids, plasma a nonpruritic, erythematous, maculopapu- with persistent fever and neck/back pain. exchange, and intravenous immunoglobu- lar rash that involved primarily his chest, She had been evaluated at an outside hos- lin. Outcome of ADEM is generally favor- abdomen, legs, and arms. Skin biopsies pital 2 weeks prior to the current presenta- able in the pediatric population but mor- were obtained and results were consistent tion and was treated for aseptic meningitis tality levels in adults can be high, especially with a diagnosis of neutrophilic eccrine based on inconclusive imaging and cere- in patients requiring intensive care unit hidradenitis (NEH). brospinal fluid (CSF) analysis. Pertinent admission or presenting with multiphasic Discussion: NEH is an extremely rare physical exam findings were pain with forms.

VOLUME 111 • NO. 2 75 A Rare Complication Associated receptor may cross react with thyrotropin Results: In the fully adjusted models in with Graves’ Disease binding moieties on neutrophils leading to women, eGFR-MDRD was inversely asso- Emily J. Guerard, MD, Diana Maas, MD; neutrophil destruction. The treatment for ciated with height (β =p -0.08; = 0.012), Medical College of Wisconsin, Milwaukee, Wis neutropenia secondary to Graves’ disease lean mass percentage (β =p -0.06; = 0.047), Introduction: Graves’ disease is an auto- is regulating thyroid function. In addition, and grip strength (β =p -0.15; < 0.001), and immune disease that results in an overac- methimazole rarely causes agranulocytosis eGFR-CKD-EPI was inversely associated tive thyroid gland. Autoantibodies act to resulting in neutropenia; but in the case with grip strength (β =p -0.08; = 0.001). stimulate the thyroid stimulating hormone described above, this was very unlikely as In men, there was an inverse association (TSH) receptor ultimately leading to an the patient had been off methimazole for between eGFR-MDRD and lean mass excessive production of T3 and T4. Several months. It is important to recognize this percentage (β =p -0.10; = 0.013) and grip autoimmune diseases like Graves’ disease rare complication associated with Graves’ strength (β =p -0.12; = 0.022) and between are known rarely to be associated with disease and to promptly treat the underly- eGFR-CKD-EPI and lean mass percentage neutropenia. ing thyroid dysfunction. (β =p -0.07; = 0.018). However, there was Case: A 33-year-old African-American no association between eGFR calculated woman presented with a 1-year history of Relationship Between Body using either of the 2 equations and weight, palpitations, poor appetite, weight loss, Composition and Glomerular BMI, BSA, lean mass, or fat mass. lightheadedness, and heat intolerance that Filtration Rate Estimates in the Conclusions: The inverse relationship had worsened acutely 2 weeks prior to General Population between eGFR and measures of muscle Sverrir I. Gunnarsson, Department of admission. She had a history of Graves’ Medicine, University of Wisconsin Hospital mass and muscle strength suggest that hyperthyroidism that was diagnosed 2 and Clinics, Madison, Wis; Runolfur Palsson, incorporation of these variables might years prior. At the time of diagnosis, she Olafur S. Indridason, Division of Nephrology, improve eGFR prediction from serum cre- was started on methimazole, but she dis- Department of Medicine, Landspitali – The atinine in the general population. continued the medication about 6 months National University Hospital of Iceland, prior to admission because she felt it was Reykjavik, Iceland Spontaneous Hemorrhage into the no longer controlling her symptoms. On Background: Differences in body composi- Mediastinum from a Parathyroid physical exam, her pulse was 130. She tion, (ie, lean mass or lean mass percent- Adenoma appeared flushed and mildly diaphoretic. age) may be responsible for imprecision Jingbo Huang, MD, Athanasios Soskos, She had mild exophthalmos but no lid lag. in estimated glomerular filtration rate MD, Safwan Murad, MD, Steven Yale, MD, Her thyroid gland was tender to palpation (eGFR) estimates from serum creatinine. Andrew Urquhart, MD; Marshfield Clinic and Marshfield Clinic Research Foundation, and markedly enlarged. Her reflexes were In this study, we examined the relationship Marshfield, Wis hyperactive. On admission, her TSH was between the eGFR and anthropometric Introduction: Extracapsular hemorrhage undetectable, free T3 >32.6 pg/ml, and and body composition measures in a large of a parathyroid adenoma is extremely free T4 >7.77 ng/ml. She also was found cohort. rare yet should be considered in a patient to be leukopenic with a white blood cell Methods: We analyzed data from a cross- presenting with spontaneous bleeding in count of 2600/cu ml and an absolute neu- sectional study on bone health compris- the neck and mediastinum. The etiology trophil count of 670/cu ml. The patient ing 1630 randomly selected community- of this occurrence is currently unknown. was admitted with severe thyrotoxicosis dwelling adults 30 to 86 years old. The Elevated PTH (parathyroid hormone) and secondary to Graves’ disease. Her leuko- Modification of Diet in Renal Disease calcium levels with specific radiological penia and neutropenia were thought to be (MDRD) and Chronic Kidney Disease due to an autoimmune process rather than Epidemiology Collaboration (CKD-EPI) findings are useful in diagnosis. methimazole. She was started on propyl- equations were used to calculate eGFR Case: A previously healthy 56-year-old thiouracil and prednisone for her hyper- from IMDS-standardized serum creatinine. female presented with a 3-day history of thyroidism and propranolol for symptom Body mass index (BMI) and body surface progressive intermittent left neck pain and control. She was referred to endocrine area (BSA) were calculated from measured dysphagia. She denied fever, chills, weight surgery for definitive management of her height and weight. Body composition was loss, recent trauma, history of hyperpara- Graves’ disease. determined by dual-energy x-ray absorpti- thyroidism, anticoagulation, or NSAID Discussion: The association between ometry, and grip strength was measured. use. On physical examination, the patient Graves’ disease and neutropenia is thought Linear regression models adjusted for age, was afebrile with fullness over the left lower to be due to the production of antineutro- hypertension, diabetes, and smoking were neck without ecchymosis. CT of the chest phil autoantibodies. It also is speculated used to examine the association between and neck was suggestive of an inflamma- that the autoantibodies against the TSH eGFR and the variables of interest. tory process involving the superior and

76 WMJ • APRIL 2012 posterior mediastinum and an ill-defined, malaise for 4 weeks. Her symptoms began the first 3 months of therapy. The median enhancing mass in the left tracheoesopha- immediately after initiation of propyl- time to resolution of agranulocytosis is 10 geal groove, starting at the midportion of thiouracil (PTU) therapy for recurrence to 14 days. Case reports and a small pro- the posterior aspect of the thyroid. of hyperthyroidism, though she failed to spective study have not shown an improve- Laboratory studies showed WBC 4.9 x report this until the day before admission. ment in recovery times with G-CSF. 103/uL, hemoglobin 12 g/dl, serum cal- She was diagnosed with Graves’ disease in Instead, discontinuation of the thionamide cium 11.1 mg/dl (normal 8.5-10.3 mg/dl), 1996 and initially treated with methima- and supportive treatment with antibiot- and ionized calcium 6.5 mg/dl (normal zole. However, she did not tolerate this ics for neutropenic fever is recommended. 4.7-5.5 mg/dl). PTH was elevated at 101 and was switched to PTU. She received Then either RAI or thyroidectomy should pg/ml (normal 7-53 pg/ml). Her hemo- this therapy for 2 years, after which time be pursued for definitive treatment. globin dropped to 8.9 g/dl over the next 3 it was stopped due to remission of her dis- days although she remained hemodynami- ease. At this presentation, the patient had Another Great Masquerader Rachel Johnson; Medical College of Wisconsin, cally stable. MRI of the chest and neck a temperature of 100.3°F, rigors, exudative Milwaukee, Wis showed a diffuse process within the lower tonsil lesions, and an erythematous phar- neck extending into the superior mediasti- ynx. She had a mild normocytic anemia Introduction: Human immunodeficiency num suggestive of a hematoma with bilat- (hemoglobin 9.2 g/dL) and thrombocyto- virus (HIV) is an increasingly prevalent eral pleural effusions. Left neck exploration penia (platelet count 123 e3/uL), but more disease, and early diagnosis is important showed an enlarged left superior parathy- substantially her white blood cell count to prevent the spread of infection and to roid adenoma with surrounding blood clot (WBC) was 1.3x10^9/L with an absolute begin prompt treatment. Acute retroviral and fibrin. Symptoms resolved postop- neutrophil count of zero, TSH was 0.015 syndrome (ARS) describes the clinical signs eratively with normalization of PTH and µU/mL. PTU was discontinued after con- and symptoms of primary HIV infection, serum calcium levels. A subsequent chest sultation with hematology affirmed con- which includes the period from initial HIV x-ray revealed complete resolution of the cern for PTU-induced pancytopenia. She infection to HIV seroconversion. pleural effusions. was not started on granulocyte colony Case: A 19-year-old man with a past medi- stimulating factors (GCSF) since little evi- Discussion: Spontaneous hemorrhage of cal history of chronic constipation and sea- dence suggested a benefit in PTU-induced a parathyroid adenoma is extremely rare. sonal allergies presented with complaints agranulocytosis. The patient had recov- Hemorrhage may be confined to the cap- of rectal pain for 1 week along with fever, ery of neutrophils on hospital day 10 to sule or extend, as in this case, extracapsu- chills, and malaise. Prior to presentation, 1.8x10^9/L. Her neutrophils remained larly. Symptoms depend on the size of the he had been evaluated at an outside hos- above 1.5 x10^9/L during the remainder adenoma and hematoma and may include pital and underwent a rectal exam under of the hospital stay, and she had a WBC a neck mass, swelling, pain or discomfort, anesthesia with no identification of abnor- of 4.8 x10^9/L, hemoglobin 11.8g/dL, bruising, ecchymoses, dysphagia, hoarse- malities. On presentation at our institu- and platelet count of 265e3/uL on the day ness, or dyspnea. Predisposing factors tion, physical exam was significant for a of discharge. She underwent radioactive include trauma, use of anticoagulants or low-grade fever, maculopapular rash on his iodine ablation (RAI) for definitive treat- NSAIDs, and the imbalance between the torso, and perianal mucosal ulcerations. ment. growth of the adenoma and available vas- Initial lab evaluation was significant for cular supply. Diagnosis of spontaneous Discussion: Thionamides (PTU and elevation of hepatic transaminases and rupture of a parathyroid adenoma without methimazole) are first-line options for thrombocytopenia. He was admitted for provoking factors is challenging. A high treatment of Graves’ disease, with methim- further treatment and evaluation, and cef- index of clinical suspicion is required in azole being preferred in nonpregnant triaxone was initiated to cover for Gram- order to make an accurate diagnosis. patients since it is more effective with positive bacterial infections, including sexu- fewer side effects. Agranulocytosis is a ally transmitted diseases. Rectal swabs were Propylthiouracil: Suppressing More rare, serious complication of thionamides negative for herpes simplex virus (HSV) Than Thyroid Hormone occurring in 0.3% of patients, with pan- and bacteria, including group A strepto- Thomas Jensen, Reshma Pahuja, Jerald cytopenia being even more rare. Therefore, coccus and H. ducyeri. Further laboratory Marifke; Medical College of Wisconsin, physicians and patients must be aware of workup was negative for viral hepatitis, Milwaukee, Wis symptoms of agranulocytosis, discontinue syphilis, gonorrhea, and chlamydia. Initial Case: A 56-year-old woman with a past the medication, and perform further evalu- HIV antibody assay also was negative, but medical history of Graves’ disease pre- ation immediately. Routine monitoring is serum HSV serologies (IgG and IgM) were sented with a chief complaint of fever, not recommended since agranulocytosis positive. When informed of his HSV infec- chills, nonproductive cough, and general develops suddenly, though typically within tion, the patient admitted to having 13

VOLUME 111 • NO. 2 77 male sexual partners in the last year, which Fulminant Pseudomembranous Discussion: C. difficile is a spore-forming prompted concern for an acute retroviral Colitis Gram-positive rod that produces 2 exotox- infection. HIV RNA polymerase chain Scott Kagie; Medical College of Wisconsin, ins (A and B) and typically causes infec- reaction (PCR) was ordered and revealed Milwaukee, Wis tions in the setting of antibiotic use and an HIV viral load of over 700,000. The Introduction: Clostridium difficile is a cause immunosuppression. It is believed that patient was discharged home with outpa- of pseudomembranous colitis that com- alterations in the normal flora caused by tient infectious disease clinic follow-up. As monly presents as diarrhea after antibiotic antibiotics and immune dysfunction allow an outpatient, antiretroviral medications use. Diagnosis of this disease may be dif- C. difficile competitive and selective advan- were started, and the patient’s HIV viral ficult in patients with other chronic gastro- tage in the gut flora. Exposure to the bac- load eventually became undetectable after intestinal disease and may lead to increased teria at the time of antibiotic use is not 6 months of therapy. morbidity and mortality. always necessary due to its presence in the normal flora of 2% to 5% of the general Discussion: The initial presenting signs and Case: A 45-year-old woman with celiac population. The clinical presentation can symptoms of acute retroviral syndrome are disease presented with diarrhea, vomiting, range from a few days of mild diarrhea to abdominal pain, laryngitis, rhinitis, and often nonspecific. The most common pre- life-threatening pseudomembranous coli- fever. She had not been adhering strictly sentation is an acute mononucleosis-like tis. Although C. difficile is a well-known to a gluten-free diet, and she recently had illness characterized by fever, sore throat, cause of diarrhea, diagnosis in patients with undergone treatment with cephalexin for and lymphadenopathy. Other symptoms other gastrointestinal diseases sometimes a toenail infection. She also was exposed include lethargy, malaise, myalgias, weight may be missed. loss, headache, and a diffuse maculopapu- to sick contacts through her employment lar rash. Acute retroviral syndrome also can at an assisted living facility. Initially, she My Blood Gets Too Thin with Warfarin involve multiple organ systems. Muscosal was started on zanamivir for likely influ- Amritha C Karkera, MD, Ronald Go, MD, ulcerations of the oropharynx, esophagus, enza infection, and she returned home. FACP; Gundersen Lutheran Medical Center, La Crosse, Wis and the genitalia have been reported to The next day her symptoms became worse and she reported to a different clinic where occur in 28 %, 17 %, and 6 % of patients Case: An 85-year-old man presented to the she was referred to the emergency depart- respectively. Involvement of the gastroin- hospital with shortness of breath and cough- ment (ED) due to dehydration and an testinal system can include vomiting and ing up blood. He had been admitted just 2 acutely tender abdomen. On examina- diarrhea along with pancreatitis, colitis, weeks prior for non-ST Segment Elevation tion, her abdomen was soft but tender in and epiglottitis. Hepatitis is a common Myocardial Infarction (NSTEMI), atrial the periumbilical region with guarding. fibrillation with rapid ventricular rate presentation that often resolves as the Abdominal CT revealed pancolitis but no (RVR), bilateral pneumonia and was dis- host’s immune system gains control over free air. Her white blood cell count was charged on warfarin 4mg per day for atrial the initial viral replication. Other labora- 18,100/mm3, and her stool C. difficile fibrillation and moxifloxacin for pneumo- tory abnormalities include anemia, leuco- nucleic acid amplification test (NAAT) was nia. International normalized ratio (INR) penia, and thrombocytopenia. Neurologic positive. She felt significantly better the on discharge was 1.3. After discharge, INR involvement most commonly includes next day after receiving intravenous (IV) was monitored closely due to drug interac- headaches but also can include aseptic hydration, oral vancomycin, and antiemet- tion between warfarin and moxifloxacin. He meningitis or encephalitis. The signs and ics. She was discharged home on metroni- did well, but a few days later had to stop symptoms of ARS usually begin within 2 dazole and recovered to her baseline over taking warfarin due to supratherapeutic to 4 weeks of initial HIV infection and the next 3 days. She then had a recurrence INR. He then started developing progressive last approximately 2 to 3 weeks. During of symptoms 11 days later and reported shortness of breath followed by nose bleeds the primary HIV infection, the viral load to the ED. She again tested positive for and hemoptysis for which he presented in is very high and the patient is highly infec- C. difficile and was started on oral vanco- the TEC and was found to be hypoxic with tious. Early identification is important, not mycin and IV metronidazole. Her abdo- Pa02 of 49.7 on 3L. INR was noted to be only for initiation of antiretroviral therapy men was soft but more tender than before. > 9 and partial thromboplastin time (PTT) to preserve the host’s immune responses, On hospital day 2 her abdominal pain and was 67.3. Direct visualization of nasophar- but also to decrease transmission through diarrhea worsened significantly. Surgery ynx with a rigid scope revealed areas of scab- patient education and therapy. Clinicians was consulted and an exploratory laparot- bing and old bleeding sites in the left ante- should have a high index of suspicion of omy was deemed necessary. She underwent rior naris. Vitamin K and multiple units of ARS in patients with generalized mononu- total colectomy with end colostomy. Her fresh frozen plasma (FFP) were given; INR cleosis-like symptoms and risk factors for condition improved after surgery, and the dropped to 1.6 but climbed up again requir- HIV infection. rest of her hospital stay was uneventful. ing additional doses of vitamin K.

78 WMJ • APRIL 2012 Patient had not taken more warfarin than ing hips, none had been revised for aseptic ing its etiology, its exact mechanism still recommended nor was there evidence of loosening and one was loose. No signifi- remains a mystery. It is important to con- him taking super warfarin or brodifacoum. cant difference between the 2 groups with sider PLMT in a patient with painful legs Brodifacoum levels were checked and were regard to clinical outcome or perioperative and/or restless leg syndrome without any negative. Wafarin levels checked during complications was found. significant history of neurological disease his hospital stay revealed warfarin level of Conclusion: Uncemented tapered stems or trauma. Diagnosis is essentially clinical, <1 despite an INR of 2. He was tested for provide excellent fixation in obese and non- and treatment is complex, including dif- VKORC1 and CYP450 2C9 and found to obese patients out to 27 years. ferent combinations of drugs and invasive have genetic polymorphism involving both techniques with a poor outcome. genes resulting in decreased production of Unraveling the Mystery: A Patient with an enzyme that metabolizes the active iso- Dancing Feet Lactic Acidosis and Confusion mer of warfarin to inactive products and Roy Liu, Mohammed Moizuddin, MD FACP, After a Fall also decreased availability of vitamin K, Medical College of Wisconsin, Milwaukee, David Niccum, MD; Medical College of Wisconsin, Milwaukee, Wis making him very sensitive to warfarin. Wis; Serena Hung, MD, Biogen Idec, Inc, Cambridge, Mass Introduction: Confusion is a common rea- Does Size Matter? Uncemented Introduction: Painful legs and moving toes son for patients seeking urgent medical Total Hip Arthroplasty in Obese vs (PLMT) syndrome is a rare medical dis- care. The causes are numerous with many Non-Obese Patients: An 18- to 27-Year order characterized by involuntary move- that are potentially life-threatening, includ- Follow-up Study ments of the toes or the whole foot and ing toxic ingestions. Kyla Lee, MD, FACP; Gundersen Lutheran pain in lower limbs. Case: Medical Center, La Crosse, Wis. A 52-year-old male presented with Case: A 63-year-old man presented with confusion and loss of coordination 24 Introduction: This study’s purpose was to complaints of involuntary movements in hours after a fall with a binge drinking evaluate the incidence of aseptic loosening both legs over the last 8 to 10 years. These episode. During evaluation at an emer- with use of an uncemented tapered femoral movements could be momentarily sup- gency department the evening of his fall, component in obese vs nonobese patients pressed by voluntary action and did not a head CT and basic metabolic panel were at 18 to 27 years (mean 23.5 years). persist during sleep. He also described a unremarkable. At breakfast his wife noted Methods: Between 1983 and 1987, 285 con- deep, aching, burning pain with fluctuating he was experiencing slowed and inappro- secutive uncemented total hip arthroplas- intensity in both legs. Electrodiagnostic, priate speech and difficulty coordinating ties were performed with use of a tapered laboratory, and imaging studies were nor- his gait. By the time he was admitted, his stem. The patients were divided into 2 mal. Physical exam revealed semi-rhythmic neurologic exam had become unremark- groups, obese and nonobese, as determined flexion-extension and occasional abduction able. Initial laboratory evaluation showed by their body mass index (BMI). There of the phalanges in both feet, especially an increase in creatinine to 1.11 from 0.76 were 105 obese patients (119 hips, BMI ≥ the great toes, characteristic of PLMT syn- mg/dl and a decrease in bicarbonate to 16 30) and 156 nonobese patients (166 hips, drome. from 28 mg/dl the day prior. An arterial BMI < 30). The outcome of every femo- Discussion: Spinal cord and cauda equina blood gas showed an anion gap metabolic ral component with regard to stem fixa- diseases, neuropathies, radiculopathies, acidosis with respiratory compensation. His tion, revision, or retention was determined drugs, and other systemic diseases are the serum lactate also was elevated markedly at for all 285 hips. Complete follow-up was main causes of this syndrome, although 23 mmol/L. Urinalysis revealed occasional obtained on the 97 patients (111 hips) sur- many cases still are idiopathic. The invol- calcium oxalate crystals. Upon further viving a minimum of 18 years (range 18 to untary movements appeared bilaterally questioning, the patient admitted to an 27 years). in the toes in our patient, which suggests attempted suicide prior to his fall by con- Results: Of the 119 hips in obese living and that central reorganization (especially in suming 1 cup of ethylene glycol. Ethylene deceased patients, 1 stem (1%) had been the spinal level) is the cause of PLMT. glycol level subsequently returned at 135 revised for aseptic loosening and one was Electromyogram (EMG) and nerve con- mmol/L. He was started on a fomepizole loose by radiographic criteria. In the 55 duction studies have proven helpful in and bicarbonate drip and his anion gap surviving hips, none had been revised for demonstrating spontaneous arrhythmic acidosis resolved within 24 hours. aseptic loosening and one was loose. bursts of affected muscles and the underly- Discussion: Ethylene glycol is a widely avail- Of the 166 hips in nonobese living and ing neuropathy in some patients. able chemical found in industrial products. deceased patients, none had been revised Conclusion: Physicians should be aware of It is responsible for dozens of deaths in for aseptic loosening and one was loose this rare debilitating condition. Though the United States annually. While ethylene by radiographic criteria. In the 56 surviv- much progress has been made in elucidat- glycol itself is relatively nontoxic, it is bro-

VOLUME 111 • NO. 2 79 ken down into calcium oxalate and other radiological improvement. He started emergency department (ED) with left- harmful metabolites that can cause oliguric complaining of lower abdominal pain. sided upper abdominal pain of 1 day dura- or anuric acute kidney injury. Usual pre- Colonoscopy revealed superficial ulcer- tion with emesis, bloody diarrhea, right sentations include development of mild ations and erythema in the ascending colon. upper arm pain, and cramping. On physi- central nervous system (CNS) effects such Fusiform-shaped larva were noticed on cial exam, he was diaphoretic, tachycardic, as inebriation and sedation, which are exac- the cecal biopsy. A positive repeated stool afebrile. Right upper arm, shoulder, and erbated with coingestion of ethanol. Other ova and parasite indicated Strongyloides forearm and lateral chest wall were signifi- neurologic symptoms include cranial nerve stercoralis. A 2-day regimen of ivermectin cant for swelling and mottling of skin with palsies, tetany, and cerebral herniation in was given, corticosteroids dose decreased. moderate tenderness and crepitence. X-ray large doses. Renal manifestations are oligu- He returned 4 days later with progressive showed extensive subcutanous emphy- ria and hematuria due to crystal deposition. shortness of breath and was found to have sema. Antibiotics were started. Emergency Workup in suspected poisonings should pneumothorax and persistent diffuse bilat- surgical debridement and fasciotomy were include basic chemistries, arterial blood gas, eral lung infiltrates. His condition deterio- performed. The arm was not salvagable serum osmolality, and electrocardiogram rated with respiratory failure and failure to and amputation was performed. Post- (ECG). It also is important to rule out co- thrive. At that point, the patient and fam- operatively, patient developed septic shock ingestion and establish the level of inges- ily opted to discontinue treatment. He was and was on mechanical ventilation. The tion. Treatment in mild to moderate levels eventually discharged to hospice care and culture from debridement was positive for of ingestion consists of competitively inhib- expired shortly after. Clostridium septicum. Abdominal CT did iting alcohol dehydrogenase and normaliz- Discussion: Strongyloidiasis in immuno- not show any masses. After resolution of ing the patient’s pH, with bicarbonate drip competent hosts is asymptomatic, often septic shock and weaning from ventilation if necessary. More profound ingestions may limited to incidental finding of periph- the patient underwent colonoscopy, which require acute hemodialysis for the removal eral blood eosinophilia. However, in showed a 3-cm ascending colon mass; of this toxic and often lethal chemical. immunocompromised hosts, it often causes pathology report presented as tubulovillous ademona with intramural adenocarcinoma. A Case of Strongyloidiasis Unmasked disseminated disease. Our patient most Patient underwent hemicolectomy and was by Corticosteroids likely acquired the infection in Puerto Rico Piangwarin Phaosawasdi, Aurora Health Care where he worked as a farmer. He was asymp- staged as IIIa (Dukes C). Internal Medicine Residency Program, Aurora tomatic until he received high dose cortico- Discussion: This case represents the impor- Sinai Medical Center, Milwaukee, Wis steroids, which unmasked the diagnosis. tance of association between rare cases of Introduction: Most cases of strongyloidiasis Clostridium septicum nontraumatic gan- in the United States are subclinical. They Spontaneous Upper Extremity grenous myonecrosis and occult malig- may occur seldom in debilitated or immu- Myonecrosis Secondary to Clostridium nancy. It emphasizes the need for extensive nocompromised patients, and immuno- Septicum: Clue to Colonic Malignancy workup to exclude malignancy, especially Katarzyna Piotrowska, Aurora Health Care suppressive agent recipients. We describe colorectal cancer. Internal Medicine Residency Program, Aurora an unusual case of strongyloidiasis with Sinai Medical Center, Milwaukee, Wis intestinal and pulmonary manifestations in Recurrent, Reversible Acute Kidney a Puerto Rican immigrant. His disease was Introduction: Clostridium septicum can Injury: Puzzles, Pointers, and the Allure unmasked after receiving high dose corti- be differentiated from other Clostridium of Internal Medicine costeorids for pneumonitis. species by causing nontraumatic gas gan- Radmila Savcic-Kos, MD, Suresh Hosuru, MD, grene in tissues. Once culture is positive Narayana Murali, MD; Marshfield Clinic – Case: Our patient was a 75-year-old Puerto for Clostridium septicum in gangrenous Ministry Saint Joseph’s Hospital, Marshfield, Rican man with multiple admissions over tissue, suspicion of colorectal malignancy Wis the past 3 months for progressive short- should be high. By hematogenous spread, Introduction: Sarcoid, noncaseating granu- ness of breath of uncertain etiology. He Clostridium septicum will cause nontrau- lomatous interstitial nephritis (GIN) is an was diagnosed with asthma exacerbation underrecognized entity of a well-known and treated with corticosteroids, antibiot- matic gas gangrene in immunocompro- ics, and bronchodilators. Prior to receiving mised patients with colorectal malignancy. disease. Although first described in 1933 corticosteroids, he had modest peripheral The case report will portray a need for by Garland and Thomson, less than 50 eosinophilia. Extensive workup led to a workup for underlying malignancy in the case reports exist in literature. In 1 autopsy diagnosis with acute respiratory distress setting of spontanous nontraumatic gan- series, 20% of patients with sarcoidosis syndrome of unknown etiology with dif- grenous Clostridium septicium myonecrosis. were noted to have GIN. fuse alveolar damage on biopsy. High-dose Case: A 49-year-old man with no signifi- Case: We report a 76-year-old man who was corticosteroids did not lead to clinical or cant past medical history presented to the referred for nonoliguric acute kidney injury

80 WMJ • APRIL 2012 (AKI) (baseline creatinine of 1.3 mg/dL Papillary Thyroid Cancer in ther evidence that the familial form of pap- in September 2009 and 2.2 in September Monozygotic Twins illary carcinoma of the thyroid may exhibit 2010) in the background of hypertension Amine Segueni, Ilhem Remmouche, Elaine C. aggressive behavior. on fosinopril, atrial fibrillation on war- Drobney; Aurora Health Care Internal Medicine Residency Program; Aurora Sinai Medical farin therapy, prostatic adenocarcinoma An All-Consuming Case Center, Milwaukee, Wis Jonathan Thompson, Michael Kron, Shahryar (prostate-specific antigen 11.42ng/mL, Introduction: Numerous studies have dem- Ahmad; Medical College of Wisconsin, T2a Gleason grade 3+3/10), pulmonary Milwaukee, Wis sarcoidosis quiescent since 2006, and gas- onstrated a slightly greater concordance for cancer in monozygotic twins. Also, in Case: A 44-year-old man with a history troesophageal reflux disease on omeprazole. studies comparing familial with sporadic of incarceration presented with 2 weeks Clinical exam was noncontributory. papillary thyroid cancer, some investigators of headache, fever, and night sweats. He In the absence of other abnormal labora- have reported higher rates of multicentric reported progressive breathlessness, a tory parameters, failure to recover on with- tumors, lymph node metastasis, vascular 30-pound weight loss over 4 months, and holding fosinopril, increasing creatinine invasion, and local invasion in familial photophobia. His admission temperature 3.6 mg/dL, and expressed unwillingness to forms. Two case reports published in 1955 was 104°F. Chest x-ray demonstrated dif- proceed with a kidney biopsy given warfa- and 1988 emphasized the role of genetic fuse bilateral pulmonary interstitial nodular rin use, the patient was advised to discon- factors in twins with papillary thyroid can- opacities that were concerning for miliary tinue omeprazole and consider an empiric cer and we are reporting one more case tuberculosis. His serum Quantiferon tuber- trial of prednisone for possible omeprazole- diagnosed incidentally in a set of 37-year- culosis (TB) test was positive. Histoplasma, induced vs sarcoid interstitial nephritis. old monozygotic twins. blastomyces, Pneumocystis carinii, cyto- In 4 weeks, his renal indices recovered to megalovirus (CMV) and HIV assays were Case: The first twin was referred to us by negative. Bronchoscopy with bronchoal- 2.3 mg/dL and steroids were discontinued. her OB/GYN for an incidentally discov- veolar lavage was performed, but sputum However, he returned in 3 months with a ered thyroid mass. Ultrasound-guided fine acid-fast bacilli smears were negative. recurrent episode of AKI (creatinine 5.6 needle aspiration (FNA) cytology of the Empiric antituberculosis chemotherapy was mg/dL), evidence of mild hypercalcemia mass revealed papillary thyroid carcinoma; initiated with isoniazid, rifampin, pyrazin- (10.7 mg/dL), normal intact parathyroid pathologic diagnosis at the time of total amide, and ethambutol. His headache and hormone (iPTH) and polyuria. The clini- thyroidectomy indicated multifocal disease photophobia worsened. Cerebrospinal fluid cal pointer led to a kidney biopsy in the with metastases to local lymph nodes. absence of pulmonary evidence of active (CSF)analysis showed 85 WBC with 9% The second twin, healthy and completely sarcoidosis and a differential of metastatic lymphocytes, protein of 70mg/dL, glucose asymptomatic, was referred to us by her of 47mg/dL and a negative acid-fast bacil- prostatic carcinoma. It confirmed nonca- sister for screening. Thyroid ultrasound lus (AFB) smear. Brain MRI showed innu- seating granulomatous involvement, with- showed bilateral small thyroid nodules, one merable supra and infratentorial 3-6 mm out acid-fast bacilli or evidence of vascular of which was confirmed by FNA to be pap- ring enhancing lesions with surrounding involvement. He was restarted on steroids, illary carcinoma. Interestingly, she too was edema, consistent with tuberculomas. The with dramatic improvement in renal indi- found to have metastatic disease at the time final diagnosis was miliary tuberculosis with ces (creatinine 2.3 mg/dL, Ca 8.8, iPTH of surgery. Post ablation total body radioio- intracranial tuberculomas. Dexamethasone 70 in 4 weeks of treatment). dine scan detected persistent activity in the was added to his antituberculosis chemo- Conclusion: In addition to highlighting all thyroid bed—not an uncommon finding. therapy, with rapid resolution of his head- facets of sarcoidosis and renal GIN, this Within the following 6 months, the patient ache and fevers. He was discharged on case demonstrates the relevance of recog- discovered new left neck lymphadenopathy. directly observed therapy and prednisone. nizing the uncommon and sometimes sub- Lymph node mapping by ultrasound fol- After discharge, his sputum cultures grew tle, extrathoracic pointer (hypercalcemia, lowed by FNA confirmed bilateral meta- Mycobacterium tuberculosis. past response to empiric steroid trial) of a static papillary carcinoma. The patient was CNS tuberculosis occurs in 1% of all TB relatively common disease. Furthermore, referred for elective neck dissection; post- cases in immunocompetent individu- it underscores the allure of conundrums operative thyroglobulin level and imaging als. It carries a 15% to 40% mortality. in medical practice that are not only chal- results are pending. Tuberculomas are extremely uncommon lenging but also profoundly satisfying. This Discussion: Although the genetic basis for in the West, but they account for 20% to patient clearly had an eminently curable familial papillary thyroid cancer is yet to 30% of intracranial space occupying lesions disease that was otherwise relentless and be completely understood, screening with in children in India and Asia. Classic CSF destined to saddle him with dialysis and its ultrasound and FNA is warranted in mono- findings include low glucose and high antecedent morbidity. zygotic twins, as this report provides fur- protein and cell counts (with lymphocytic

VOLUME 111 • NO. 2 81 predominance). Serial CSF AFB smears antineutrophil cytoplasmic antibodies adenopathy, or petechiae/purpura and was greatly improve the diagnostic sensitivity. (c-ANCA) and anti-proteinase 3 (PR3) otherwise unremarkable. His complete TB CSF polymerase chain reaction (PCR) antibodies. Also at this time, fungal cul- blood cell count (CBC) revealed WBC has 55% sensitivity and 95% specificity. ture from bronchoaveolar lavage grew a 5.4, Hb 14.6 and platelets 35. His creati- Typically, isoniazid, rifampin, ethambutol, slow-growing mold, later identified as nine was 4.3 mg/dL indicating acute kid- and pyrazinamide are used for 2 months, blastomycosis. Ultimately, the patient was ney injury and his lactate dehydrogenase with isoniazid and rifampin being contin- diagnosed with both Wegener’s granulo- (LDH) was 619 U/L. His smear revealed ued for a total of 12 months (18 months matosis without renal involvement and numerous burr cells but very few schisto- with tuberculomas). Multiple randomized blastomycosis, and was treated for both cytes. Hemolysis labs were negative. He control trials have demonstrated decreased with IV cyclophosphamide, prednisone, was admitted to the intensive care unit mortality in patients who receive steroids in and itraconazole. Follow-up chest radiog- (ICU), volume resuscitated, and started the treatment of TB meningitis. raphy showed improvement of the lung on broad-spectrum antibiotics. Given his lesions with clinical improvement of the constellation of symptoms, there was con- A Tale of 2 Granulomas conjunctivitis. cern for TTP hemolytic uremic syndrome Amalia Wegner, MD, John Bellizzi, Jr., MD; Discussion: Wegener’s granulomatosis and Medical College of Wisconsin, Milwaukee, Wis (HUS), so plasmapheresis was begun. His blastomycosis are 2 rare granulomatous mental status began to improve before Introduction: Wegener’s granulomatosis diseases, one being an autoimmune disease plasmapheresis was started however, and and blastomycosis are both granuloma- process and the other a fungal infection. further history revealed that the patient tous diseases that are difficult to diagnose, Diagnosis of either can be challenging, bred horses in rural Wisconsin and admit- especially if both simultaneously affect the and diagnosing both at the same time can ted to multiple tick bites. Subsequently, lung. Accurate diagnosis is important as it be a diagnostic dilemma. Part of diag- Anaplasma and Ehrlichia DNA PCR tests, has therapeutic implications. nosing either is based on a good history. Lyme screen, and Babesia smear were col- Case: We describe a 74-year-old man, However, there can be atypical presenta- lected. Doxycycline was started for empiric ex-smoker, who presented with a 2-week tions, which require more focus on serol- treatment of tick-borne illness. The history of bilateral conjunctivitis with left ogy and histology. patient’s clinical condition, kidney func- dacroadenitis. He was seen by ophthalmol- tion, and platelet count improved in the ogy 1 week prior to admission, when he VIGNETTES first 36 hours. Anaplasma phagocytophilum Anaplasmosis as a Mimicker of was diagnosed with bilateral conjunctivitis DNA returned positive 3 days later and and presumptively treated with antibacte- Thrombotic Thrombocytopenic his ADAMTS13 activity returned nor- rial eye drops. However, the conjunctivitis Purpura mal, further proving that he did indeed worsened warranting a hospital admission, Joshua Barocas, MD, Saurabh Rajguru, MD; have anaplasmosis and not TTP-HUS. during which chest radiography demon- University of Wisconsin Hospital and Clinics, Madison, Wis He required no further interventions and strated an area of lobar consolidation. was discharged in stable condition with a The patient initially was treated for com- Introduction: Anaplasmosis is an illness 3-week course of doxycycline. munity-acquired pneumonia and bilateral endemic to the upper Midwest trans- conjunctivitis with IV antibiotics without mitted by Ixodes scapularis. It can mimic Discussion: Anaplasmosis and other tick- improvement in either the lung consolida- thrombotic thrombocytopenic purpura borne illnesses can present similarly to tion or conjunctivitis/left dacroadenitis. (TTP) insofar as it presents with throm- TTP-HUS, however there is no evidence Initial and repeat eye cultures were nega- bocytopenia, fevers, altered mental sta- of microangiopathic hemolytic anemia in tive. Bronchoscopy with washing and tus, and acute kidney injury, but without the former. Tick-borne illnesses should be biopsy of the lung lesion demonstrated microangiopathic hemolytic anemia. Early added to the differential depending on sea- numerous inflammatory cells without recognition in endemic areas can prompt son and geographic location. This patient’s malignant cells. Subsequently, the patient rapid resolution and proper utilization of initial improvement can be attributed to underwent a CT-guided core biopsy with health care resources. prompt treatment with antibiotics and the same results aforementioned. He Case: A 59-year-old man with coronary not due to the plasmapheresis he received. was continued on IV antibiotics without artery disease (CAD) presented with 2 Prompt recognition and treatment of ana- improvement. Given that his conjunctivi- days of confusion, fevers, unsteady gait, plasmosis by internists and ED physicians tis also was not improving, biopsy of the and nonbloody diarrhea. Upon presen- can help avoid potentially unnecessary and lacrimal duct was performed and dem- tation, he was febrile, hypotensive, and expensive interventions such as plasma onstrated granulomas. Subsequent, sero- disoriented. His exam was significant for exchange, dialysis, and admission to the logic testing was positive for cytoplasmic the lack of hepatosplenomegaly, lymph- ICU.

82 WMJ • APRIL 2012 An Unusual Case of Cardiac 29.5 mg/dl, and erythrocyte sedimenta- ulcer was noted. Labs revealed anemia Tamponade tion rate (ESR) 83 mm/hour. Patient was (7.9g/dL), mild leukocytosis, and elevated Mary Bassing, MD, Gundersen Lutheran started on high-dose steroids and began to CRP (19.3 mg/dL). A Doppler ultrasound Medical Foundation, La Crosse, Wis clinically improve. He was discharged on ruled out deep venous thrombosis. A pre- Case: A 19-year-old man presented with a prednisone and itraconazole. The work- sumptive diagnosis of cellulitis with edema 1-week history of diffuse myalgias, arthral- ing diagnosis was AOSD vs disseminated was made. gias, subjective fevers, and initial sore histoplasmosis. Follow-up testing for histo- Four days later, in the absence of objective throat. At the time of admission, he also plasma Ab was negative. The patient’s final improvement and new onset acute kidney had developed chest pain and dyspnea. diagnosis was AOSD. injury (AKI, creatinine 2.6 mg/dL), he Exam revealed a pericardial rub and sinus Discussion: Adult-onset Still’s disease is was noted retrospectively to have subacute tachycardia. Lab findings included leukocy- a rare inflammatory disorder with yet persistently elevated creatinine kinase rang- tosis (WBC peak of 43.70, 91.3% granu- unclear etiology. Diagnosis may be guided ing from 564 to 369 IU/L). A urinalysis locytes), anemia, and thrombocytopenia. by the Yamaguchi criteria. The major cri- revealed diabetic proteinuria (2.54 g/mg) Chest x-ray was significant for a left lower teria include intermittent fever of at least with a benign sediment. A diagnosis of lobe (LLL) infiltrate. Transthoracic echocar- 39°C for > 1 week, arthralgias for > 2 DMN was made and confirmed by MRI diogram (TTE) revealed a trivial pericardial weeks, characteristic skin rash, leukocytosis with gadolinium. It revealed profound effusion without tamponade. Patient was with > 80% granulocytes. The minor cri- edema in the subcutaneous fat, perifascial, started on NSAIDs for pericarditis and IV teria include sore throat, lymphadenopa- multifocal enhancement of the quadri- ceftriaxone and azithromycin for presumed thy, hepatosplenomegaly, abnormal liver ceps and adductor muscles, in addition to community-acquired pneumonia. function tests, and negative antinuclear an extensive area of absent enhancement On hospital day 2, he developed right antibody (ANA)/ rheumatoid factor (RF). within the right vastus medialis suggesting upper quadrant (RUQ) pain, and an Significantly elevated ferritin levels also are muscle necrosis. He subsequently was dia- abdominal CT was significant for hepato- seen in up to 70% of patients with AOSD. lyzed temporarily to remove gadolinium. A splenomegaly and retroperitoneal/mesen- muscle biopsy was consciously withheld to teric lymphadenopathy. On hospital day Diabetic Myonecrosis: Diagnostic and avoid infection. Conservative therapy with 3, he developed increased chest pain and Therapeutic Pitfalls bed rest, analgesia, and short-term immo- dyspnea and repeat TTE was suggestive of Rajitha Dasari, MD, Sudhir Duvuru, MD, bilization resulted in improvement. Most Narayana Murali, MD; Marshfield Clinic, impending tamponade. He was intubated recent creatine kinase (CK) was 88 U/L. Marshfield, Wis secondary to acute respiratory failure, Conclusion: Heightened awareness for the and an emergent pericardial window was Introduction: Diabetes and consequent end occurrence of DMN as a complication of placed. Chest x-ray revealed diffuse infil- organ damage of retinopathy, nephropa- diabetes so frequently observed in clinical trates. Bronchoscopy/BAL were unreveal- thy, and neuropathy are well recognized. practice would facilitate prompt recogni- ing. The patient then developed a diffuse However, Diabetic Myonecrosis (DMN), tion, avoid invasive diagnostic interven- maculopapular rash and became febrile a relatively rare, potentially life- and limb- tions, and prevent iatrogenic morbidity. to 102.4°F with prior low-grade fevers. threatening complication is underrecog- Institution of conservative management Infectious disease was consulted and exten- nized and often misdiagnosed. may in all likelihood culminate in improved sive work-up was completed with negative Case: A 43-year-old morbidly obese man outcomes. This case also highlights the role cultures and testing for HIV, Epstein-Barr with poorly controlled diabetes (HbA1C of MRI as a diagnostic tool and the role virus, CMV, influenza, enterovirus/cox- 10.8% - 17.5 %) presented with a sub- for prophylactic temporary hemodialysis sackie, adenovirus, parvovirus, Lyme, ana- acute history of a very painful thigh of to decrease risk for nephrogenic systemic plasma/ehrlichia/rickettsial panel, tulare- approximately 10 to 12 weeks duration. fibrosis in the background of gadolinium mia, chlamydia, brucella, fungal antibody He denied any history of trauma, fever, exposure and AKI. panel. Anti-histoplasma Ab was positive. or chills. Musculoskeletal exam revealed Itraconazole was initiated. a profoundly swollen, tender distal right Myxedema Madness, Stertor, and Due to a largely negative infectious work- thigh without skin breakdown, erythema, Rhabdomyolysis up, lack of clinical improvement, and or crepitus, and a range of motion lim- Suresh B Hosuru, MD, Radmilla Savcic-Kos, concern for adult-onset Still’s disease ited by pain. Anterior and posterior thigh MD, Matthew Jansen, MD, FACP; Marshfield (AOSD), rheumatology was consulted. compartments were soft without evi- Clinic, Marshfield, Wis Ordered labs all were negative with the dence of elevated compartment pressures. Introduction: The clinical presentation of exception of a significantly elevated ferritin Peripheral pulses were palpable, reflexes thyroid hormone deficiency is diverse, sub- of 11,888 ng/ml, C-reactive protein (CRP) mildly diminished, and a left diabetic foot tle, and nonspecific. We describe a case of

VOLUME 111 • NO. 2 83 a patient with myxedema presenting with Pulmonary Nodules and Fever in an Discussion: Histoplasma capsulatum is a unusual clinical features of stertor and muf- Immunosuppressed Patient dimorphic fungi often present in soil. It is fled voice. Adam Meyers, MD, Karrie Martin, MD, Zouyan endemic to the Ohio and Mississippi River Lu, MD; Medical College of Wisconsin, Case: A 59-year-old man presented with valleys. Infection occurs through direct Milwaukee, Wis 1-month history of shortness of breath, inhalation of microcondidia. Primary man- stertor, and 2 days of visual hallucinations. Introduction: Histoplasmosis is a fungal ifestations depend on the degree of expo- He was diagnosed with hypothyroidism infection that presents as a flu-like ill- sure and the immune status of the host. 4 days prior to presentation and was pre- ness. It is typically self-limited in healthy Approximately 10% of immunocompetent scribed levothyroxine 100 mcg once daily. patients and resolves without interven- patients develop a self-limited flu-like ill- Physical examination showed temperature tion. In immunocompromised patients, ness characterized by fevers, chills, night 97.6°F, blood pressure 144/80 mm/Hg histoplasmosis is more likely to progress sweats, cough, and myalgias. Chronic pul- and pulse 76 bpm. He was alert and ori- to fulminant disease without intervention. monary and disseminated infections occur ented with stertorous breathing pattern. The nonspecific presentation of histoplas- most frequently in immunocompromised His voice was muffled and skin was thick, mosis in immunocompromised patients patients. Serology and antigen studies are coarse, and dry. There were no palpable challenges clinicians by fostering a broad highly sensitive and specific for differen- thyroid nodules. Lower extremities showed differential diagnosis. The potential for tiating between isolated pulmonary infec- nonpitting pretibial edema. early progression to fulminant disease in tions and disseminated disease. Effective Emergency fiberoptic laryngoscope was immunocompromised patients lends to the treatment of progressive or chronic infec- performed showing upper airway narrow- importance of an aggressive work-up and tions includes amphotericin B, fluconazole, ing with mucosal thickening. Laboratory early treatment. and itraconazole. Immunocompromised studies were significant for thyrotropin Case: A 73-year-old white woman with patients may require lifelong treatment to (TSH) 54.69 uIU/ml, CK 21963 U/L, a 30-year history of Crohn’s disease pre- prevent recurrence. aspartate aminotransferase 625 U/L, sented to her internist with a 3-day history sodium 106 mmol/L, and chloride 75 of intermittent fevers, chills, night sweats, Diagnosed Skin Deep mmol/L. Ultrasound of neck showed dif- James Mikeworth; Medical College of weakness, and arthalgias. The patient did fuse, multinodular goiter. Treatment was Wisconsin, Milwaukee, Wis not have any respiratory symptoms upon initiated with nasopharyngeal airway, con- presentation, however, her history was sig- Introduction: Pyoderma gangrenosum (PG) tinuous positive airway pressure (CPAP), nificant for a productive cough that sponta- is most often associated with inflammatory hypertonic saline 3%, IV, hydrocorti- neously resolved 1 week prior to developing bowel disease (IBD); however, rare sub- sone, and thyroid hormone replacement. fevers. The patient’s medication regimen types may be associated with underlying Hydrocortisone was discontinued when included nightly total parenteral nutrition malignancy. the results of cortrosyn stimulation test Case: A 64-year-old white man presented showed normal response. (TPN) infusions, infliximab, rifaximin, and moxifloxacin. Initial ambulatory work-up from an outside facility with a 6-week his- Discussion: Our case highlights the mul- was unremarkable for an infectious or neo- tory of a warfarin and catheter-directed tisystem clinical manifestations of myx- plastic etiology. On subsequent ambulatory thrombolysis-resistant deep vein thrombosis edema. Stertor refers to heavy snoring work-up, chest CT revealed multiple pul- and a 2-week history of two progressively sound heard during respiration. Stertor monary nodules with mediastinal and hilar enlarging ulcerations on his left leg. These and muffled voice, as seen in patients lymphadenopathy. The patient was admit- lesions were initially dime-sized, but by the with myxedema, are due to the deposi- ted and underwent bronchoscopy, which time of transfer, had progressed to diameters tion of connective tissue component in pharyngeal tissue causing airway obstruc- did not yield a diagnosis. The patient’s of 20 cm and 25 cm. His physical examina- tion. Psychiatric manifestations include symptoms continued to progress. On hos- tion was significant for left lower extremity cognitive dysfunction, affective disorders, pital day 5, mediastinoscopy yielded speci- edema and exquisite tenderness. Skin biopsy psychotic features, or so-called myx- mens containing Histoplasma capsulatum. showed a dense, diffuse, neutrophilic infil- edema madness. Failure to recognize and Subsequent serology and antigen studies trate in the superficial and deep dermis con- promptly initiate therapy with thyroid were negative suggesting nondisseminated sistent with PG. Tissue cultures were nega- hormone replacement is associated with disease. The patient was treated with flu- tive for bacterial and fungal elements. Initial mortality as high as 60%. Hydrocortisone conazole and her symptoms resolved after labs were significant for an isolated anemia should be administered until the results of 7 days. Serial CT scans at 14 and 24 weeks with hemoglobin of 8.0 g/dL, which had the cortisol levels are known since failure showed a favorable response to treatment been stable throughout his hospitalization. to treat in the presence of adrenal insuffi- with a reduction in the size and number of However, repeat assay revealed pancytope- ciency could result in adrenal crisis. pulmonary nodules. nia with WBC 4.6 x 103/uL, hemoglobin

84 WMJ • APRIL 2012 6.9 g/dL, and platelets 158 x 103/uL. Blood a week-long vacation in the Caribbean. Six Postoperative antimicrobial therapy for 6 to smear revealed 2% unclassifiable cells. In weeks later, the patient was admitted to a 8 weeks based on ESR and clinical response the context of pancytopenia and unclassifi- local hospital with gradual worsening of is recommended. able cells on the peripheral smear, a bone her chronic back pain, generalized weak- marrow biopsy was obtained to evaluate for ness, frequent falls, and episodes of confu- Early Lung Cancer Presenting myeloid malignancy. The aspirate contained sion. She was afebrile with stable vitals and as Hoarseness 33% blasts with a hypercellular core biopsy, had marked back pain with movement. M.A. Sala, K. Pfeifer; Medical College of Wisconsin, Milwaukee, Wis which confirmed the diagnosis of acute Palpation tenderness was present in the myelogenous leukemia (AML). The patient paraspinal region of her lower back. Head Introduction: Hoarseness is a symptom with was started on treatment with oral predni- CT and x-ray of lumbar spine was unre- numerous causes, including malignancy. sone, but his hospital course was compli- vealing. Blood cultures grew Salmonella Rapid determination of its source is neces- cated by an episode of atrial fibrillation with serotype Enteritidis. The patient received sary to identify serious but potentially cur- rapid ventricular response and acute kidney IV levofloxacin for 5 days, and with clinical able etiologies. injury. Due to these comorbid conditions, improvement, she was discharged with an Case: A 42-year-old white man with a he was not a candidate for induction che- additional 5 days of oral levofloxacin. 25-pack-year smoking history presented motherapy, and after initiating hemodialy- Three weeks later, the patient was readmit- with a complaint of 4 weeks of hoarse- sis, he developed acute respiratory failure. ted to the same hospital with complaints of ness. On further interview, the patient also Following a goal-setting discussion, his fam- persisting back pain, weakness, and confu- had dyspnea, productive cough without ily chose to proceed with comfort measures sion. She had a fever of 104.2°F with mid- hemoptysis, and weight loss of 50 pounds only. The patient died on hospital day 18. line lumbar tenderness. After transfer to over 3 months. Besides mild tachypnea and Discussion: PG is a rare disease often asso- our hospital for further care, we performed anxious appearance, the patient’s vital signs ciated with inflammatory bowel disease. an MRI of the spine that showed L4-L5 and physical exam were normal. Similarly, However, it has been described in other diskitis. Blood cultures and disc space aspi- his complete blood count and basic chem- disorders, including acute myelogenous leu- rate cultures grew S. enteritidis. Abdominal istry panel were within normal range, and kemia (AML). PG primarily affects young CT showed a 2-cm saccular mycotic aneu- a urine drug screen was negative. His chest to middle-aged adults, but it has been rysm of the distal abdominal aorta. While x-ray revealed densities superimposed over described in all age groups. The type of PG on ceftriaxone, patient underwent aneurys- the left upper lobe, thought to represent described in patients with underlying hema- mectomy with aortic reconstruction using either a deformity of the left 3rd rib or a tological malignancy is usually the superfi- autologous spiral saphenous vein graft. pneumonic infiltrate. Chest CT with con- cial bullous subtype of PG. It appears as Tissue culture from the resected aneurysm trast was obtained to further evaluate this an aggressive, painful, necrotic lesion with also grew S. enteritidis. She was continued finding and revealed a 2.8-cm left upper superficial bullae that break down to form on ceftriaxone for a total of 6 weeks. Her lobe mass accompanied by ipsilateral hilar an ulcerated lesion with undermined edges. pain improved and she was doing well adenopathy involving the aorto-pulmonary The surrounding skin has pathognomonic when seen 2 months later at follow-up in window (through which the left recurrent violaceous borders. The course of the skin clinic. laryngeal nerve courses). In follow-up, lesion parallels the hematological disorder. Discussion: Mycotic aneurysm is a rare but bronchoscopy with biopsy showed non- The presence of PG is an ominous sign serious complication of nontyphoidal sal- small cell lung cancer, ultimately staged as with one study citing 23 cases with only monella bacteremia, occurring most com- T2N1M0 (IIB). He was thereafter sched- 4 patients living past 8 months. Treatment monly in the abdominal aorta. This case uled for video-assisted thorascopic surgery- usually consists of steroids for the PG and demonstrates the importance of clinicians’ based resection of the neoplasm. treatment of the underlying malignancy or awareness that adults with a relapse of Discussion: Lung cancer remains the pri- disorder. As described above, outcomes gen- salmonella mary cause of cancer death in the indus- erally are poor when associated with PG. sepsis often have a serious endo- vascular infection. This risk is increased in trialized world, and diagnosis at an earlier Curse of the Caribbean patients above 50 years of age with ath- stage is more amenable to potentially cura- Deepa R. Ovian, MD, William A. Agger, MD; erosclerosis. Anti-salmonella antimicrobial tive surgical intervention. In the primary Gundersen Lutheran Medical Center, La therapy should be started and a CT or MRI care setting, historical details shown to Crosse, Wis with contrast should be performed on an be independently associated with a diag- Case: A 74-year-old woman with rheuma- emergency basis. Following diagnosis, sur- nosis of lung cancer include hemoptysis, toid arthritis treated with hydroxychloro- gical resection of the aneurysm with in situ dyspnea, cough, anorexia, weight loss, quine developed 1 episode of mild gastro- graft revascularization, the procedure of and cigarette use. Hoarseness is less often enteritis of 1 to 2 days duration while on choice, should be done as soon as possible. associated with pulmonary neoplasia but

VOLUME 111 • NO. 2 85 still caused by extra-laryngeal malignancy Hypercoagulable state was suspected due to Case: A 79-year-old woman with a history 13.5% of the time, and by lung cancer recurrent thrombosis without anatomical of cholelithiasis was brought to the ED for most often among these (6.6%). Therefore, lesions, and extensive coagulation work- generalized weakness following a flight. given the grave nature of lung cancer, it up was done that turned out negative. The Associated symptoms included weight loss, is important to consider it as an etiology patient was placed on anticoagulation, aspi- constipation, and decreased mental acuity. when assessing the complaint of hoarse- rin, and clopidogrel without bleeding com- Physical examination revealed significant ness, especially when accompanied by the plications or thrombocytopenia. To reduce muscle wasting of the thenar eminence and listed independently associated symptoms. the risk of thrombocytopenia bivalirudin a thyroid nodule. Lab work was signifi- Although the primary diagnostic modality instead of glycoprotein IIb/IIIa antagonists cant for calcium of 18.0 and PTH 1558. in evaluating hoarseness is laryngoscopy, were used for the second myocardial infarc- Initially, she was treated with pamidronate neck and chest CT should be considered tion. Prednisone was continued for mainte- and hydration. Ultrasound of the thyroid when laryngoscopy is normal or identifies nance treatment of ITP. showed mass in the left thyroid lobe and vocal cord paralysis of uncertain cause. Discussion: ITP predominantly causes a soft tissue lesion interposed between the bleeding but also may be associated with superior left thyroid lobe and common Recurrent Acute Myocardial thrombotic events. The mechanism of carotid artery. Further imaging revealed Infarction in a Patient with Immune arterial thrombosis in ITP patients is the nodule had intense sestamibi and mild Thrombocytopenic Purpura still unclear, but several hypotheses exist. iodine activity, suggestive of a thyroid can- Fengyi Shen; Aurora Health Care Internal Thrombolytic therapy is contraindicated cer with a closely associated parathyroid Medicine Residency Program, Aurora Sinai neoplasm. She received definitive therapy in acute myocardial infarction in ITP Medical Center, Milwaukee, Wis with total thyroidectomy, node dissection, patients. Primary percutaneous coronary Case: A 58-year-old white woman with and parathyroidectomy. Histopathology intervention (PCI) can be safe in this set- medical history of immune thrombocyto- showed papillary thyroid carcinoma of fol- ting. During and post PCI procedure, penic purpura (ITP) (but no known coro- licular variant, and an atypical parathyroid glycoprotien IIb/IIIa inhibitors and antico- nary artery disease history) was admitted adenoma. The parathyroid mass did not agulation should be used cautiously. Dual with shortness of breath and chest pain. clearly fit criteria for malignancy, but the antiplatelet therapy can be well tolerated in ECG and cardiac biomarkers demonstrated local invasion and presence of coagulative some patients. Another consideration that an acute ST-elevation myocardial infarc- tumor necrosis led to treating this as a para- needs to be pointed out is that the major tion (STEMI). Coronary angiography was thyroid carcinoma. Patient tolerated the goal for treatment of ITP is to provide a surgery well and was discharged from the performed urgently and revealed throm- safe platelet count rather than correcting hospital on calcitriol and close follow-up. bosis in the mid-left anterior descend- the platelet count to normal levels. ing (LAD). Aspiration thrombectomy of Discussion: Parathyroid carcinoma, atypi- the LAD was performed successfully. No A Case of Atypical Adenoma and cal parathyroid adenoma, and parathyro- lesions were detected in the LAD or other Papillary Thyroid Carcinoma matosis account for about 2% of cases of coronary arteries that required stenting. Nihad Yasmin, John C. O’Horo; Aurora Health primary hyperparathyroidism (PHPT). Heparin, eptifibatide, aspirin, and clopi- Care Internal Medicine Residency Program, This patient’s nonspecific clinical course, dogrel were instituted prior to thrombec- Aurora Sinai Medical Center, Milwaukee, Wis and extremely elevated serum calcium and tomy. The patient developed recurrent Introduction: Atypical parathyroid adenoma parathormone are typical findings of para- chest pain with new ST-segment eleva- is a rare etiology for primary hyperpara- thyroid carcinoma. The concomitant find- tions and cardiogenic shock in the follow- thyroidism. These neoplasms share some ing of associated thyroid cancer is very rare, ing 18 hours. Another coronary angiogram histologic characteristics with parathyroid only having been reported 5 times before. showed repeat extensive thrombosis of cancer but do not meet the rigorous criteria The long-term treatment plan will neces- the LAD with distal embolization. Large of cancer. One such case and a discussion of sarily involve close surveillance for recur- clot burden was painstakingly extracted the differential diagnosis of primary hyper- rence as the patient does not clearly need but distal perfusion remained suboptimal. parathyroidism are presented here. radio or chemotherapy.

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