American College of Physicians- Minnesota Chapter Annual Abstract Competition Minneapolis Convention Center October 28, 2016 Abstracts Submitted for Competition Medical Students Clinical Vignette--Medical Student Nora Ali Two Cases of Hand-Foot-and-Mouth-Disease in Immunocompetent Adults Dr. Mark P. Davis, Dr. Hand foot and mouth disease (HFMD) is a common childhood ailment. It is Megha M. Tollefson, Dr. typically caused by coxsackie virus A16, and less commonly, coxsackie B and Kendra D. Watson and Dr. enterovirus 71. Physical manifestations are characterized by vesicles on the Oluwakemi Onajin hands, feet and oral mucosa. HFMD in adults is less common and often more severe with atypical manifestations, such as widespread cutaneous involvement not limited to the hands and feet. Current literature is lacking in the characterization and outcomes of HFMD in adults. Because of the lesser frequency of HFMD in adults, it is often misdiagnosed and hence mismanaged. In this clinical vignette we describe two adult cases of HFMD to substantiate the literature on adult HFMD and guide health care providers’ management and treatment decisions. The first case is a 37-year-old man with a history of anxiety and attention- deficit disorder who presented with acute onset of rash, sore throat, fever and malaise. Physical exam revealed generalized erythematous papules over the scalp, malar cheeks, torso, upper extremities, palms, hips and right ankle. Initial differential diagnosis included hand-foot-and-mouth disease, guttate psoriasis, pitryasis lichenoides or another reactive process. Swabs for HSV, VZV, bacteria and enterovirus were collected and a representative papule was biopsied. Biopsy results showed nonspecific inflammation, hemorrhage and epidermal changes. Swab results confirmed enterovirus infection and diagnosis of hand-foot-and- mouth disease was made. The second case is a 32-year-old male with history of depression, anxiety and chronic pain who presented with acute onset of a rash that began on his face and scalp, slowly developing over his trunk, upper and lower extremities, including the palms and soles. Relevant history included recent self-limited HFMD in the patient’s daughter. Physical exam showed widespread morbilliform eruption with violaceous macules and vesicles on his scalp, face, neck, trunk and upper and lower extremities including hands and feet, as well as superficial erythematous erosions on his tongue and involving the hard palate. Differential included viral exanthem, erythema multiforme, disseminated herpes simplex and varicella infection, or Rocky Mountain spotted fever. Swab results were positive for enterovirus and diagnosis of hand-foot- and-mouth disease was made. The patient developed onychomadesis (nail shedding) shortly after diagnosis. In both cases, treatment was supportive care, including triamcinolone for the rash and hydroxyzine for itching. Both cases were self-limited. Most cases of HFMD are seen in childhood. These cases illustrate the potential for hand-foot-and-mouth disease to present in adults and the features more common in adult HFMD, including widespread, generalized rash in addition to the classic locations of the hands and feet. HFMD must be considered in the appropriate clinical scenario to avoid unnecessary work-up and treatment. 1 Victoria Blackhorse Acetaminophen-induced hemolytic anemia in an undiagnosed case of Dr. Brian Muthyala and Glucose-6-phosphate dehydrogenase deficiency Dr. Shemal Shah, A 22-year-old previously healthy male Burmese refugee was admitted to the Department of Medicine, medicine service for liver failure (AST 13,034; ALT 10,830) after a mixed University of Minnesota acetaminophen and alcohol ingestion, thought to be a suicide attempt. He was Medical School started on N-acetyl cysteine with near complete resolution of his hepatic injury. 5 days into his hospitalization, with improving ALT 1931, AST 194, and INR 1.2, his hemoglobin dropped from 15 to 5.7 g/dL. A rapid drop in hemoglobin is either due to blood loss, which was not seen, or hemolysis. His workup revealed negative Coombs, low haptoglobin, elevated LDH, and “bite cells” on peripheral smear. As these findings were concerning for G6PD deficiency, a G6PD level was sent on blood collected on admission and it returned low (6.7 U/g Hb). A Repeat G6PD deficiency test was done as an outpatient two weeks after discharge, since during an acute hemolytic episode, G6PD can be falsely depressed. The laboratory value (1.8 U/g Hb) was shown to be consistent with G6PD deficiency. Hemolysis is self-limited and should resolve within a couple of weeks. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzymatic red blood cell disorder that typically manifests in males, even though women can be asymptomatic heterozygous carriers. Affected patients are predisposed to denaturation of hemoglobin with oxidative stress leading to intravascular hemolysis. It is described primarily in individuals of Mediterranean and Asian descent. Homozygous G6PD deficient patients are asymptomatic unless they are exposed to certain triggers, such as certain foods (fava beans), infections, and drugs (sulfonamides and antimalarials). This case illustrates the exacerbation of a previously undiagnosed G6PD deficiency after acetaminophen ingestion. During periods of active hemolysis, G6PD levels may be spuriously low due to favored destruction of deficient erythrocytes; therefore, a sample should be used from before or after the acute hemolytic episode to avoid a false negative result. If testing is negative, and there is a high suspicion for G6PD deficiency, it is recommended to repeat within three months of the hemolytic episode, given a new set of circulating RBCs are produced. Previous case reports of known G6PD deficient patients going into hemolytic crisis with acute acetaminophen overdose have been readily described, however, the deficiency in our patient had not been previously identified, making this case unique. This case emphasizes the importance of back-to-basics problem solving to avoid missing a diagnosis and not overlooking adults, with a potential pediatric diagnosis, who have a hemolytic episode. Johanna Blythe Reske Drug Induced Lupus: A Rare Complication of a Common Medication Rena Singleton, MD An Uncommon Complication of a Commonly Used Medication Drug-induced lupus (DIL) is an autoimmune-mediated reaction to a medication. Associated with approximately 38 drugs, patients with DIL often present with less severe “lupus-like” symptoms. Renal involvement is less common and patients often recover after discontinuation of the offending medication and temporary treatment of drug-induced manifestations. An 80-year-old woman with a history of rheumatoid arthritis, heart failure, right splenic artery aneurysm repair, stroke and breast cancer treated with lumpectomy was transferred to the internal medicine service from the MICU after admission for acute hypoxic respiratory failure initially requiring intubation. She subsequently developed acute-onset anuric renal failure and ultimately required dialysis during admission. Initial exam findings were significant for diffuse inspiratory crackles, ulnar deviation in upper extremities, and no active synovitis or rash. It was noted that she was on hydralazine chronically for blood pressure management, and drug-induced lupus was considered in the broad differential for cause of her acute renal failure. Pertinent labs and studies during admission included a low C3 and C4 level, positive anti- 2 PR3, positive anti-MPO, and positive anti-histone. A renal biopsy was completed and showed focal segmental necrotizing and crescentic glomerulonephritis and lupus-like glomerular immune complex deposition, consistent with an ANCA-associated vasculitis. Hydralazine was promptly discontinued and the patient was started on prednisone. Plasmapheresis was initiated followed by several doses of cyclophosphamide. Renal function improved, and before hospital discharge, the patient no longer required dialysis. Rituximab was initiated and the patient was discharged with close follow-up with Nephrology and Rheumatology. This case represents an uncommon presentation of a known medication-induced complication. Hydralazine use has known association with an ANCA-positive vasculitis (typically a P-ANCA pattern), which can involve the kidney. On renal biopsy in DIL, often a necrotizing glomerulonephritis without immune complex deposition is seen, although an immune complex-mediated glomerulonephritis may be found, as it was with this patient. In retrospect, a pulmonary-renal syndrome due to drug-induced vasculitis is suspected in this patient, and ultimately she was diagnosed with a hydralazine-associated mixed drug-induced lupus/ANCA-associated vasculitis with drug-induced lupus nephritis. Early diagnosis and treatment by the multidisciplinary team caring for this patient was imperative; she was critically ill and at increased risk for significant morbidity and mortality--she had also clearly outlined her wishes to discontinue dialysis in the outpatient setting if her renal function did not recover. Identifying rare manifestations of drug-induced autoimmunity is challenging and requires a high degree of suspicion, but timely diagnosis and treatment is critical for improving patient outcomes. For this patient, early diagnosis and prompt treatment allowed for significant and meaningful recovery. Hafsa Chaudhry Fevers, Chills, and Eosinophils Jie Qu, M.D. and M. Introduction: Eosinophilia, defined