United States

Background
Enterococcus faecalis (E. faecalis) is a well-known bacterium that colonizes the human gastrointestinal (GI) tract. It is most recognized for causing antibiotic-resistant bacteremia, pneumonia, intra-abdominal infections, and endocarditis. Overgrowth in the gut and translocation to the bloodstream through the intestinal epithelium is the widely accepted mechanism for developing E. faecalis bacteremia, although the mechanisms of invasion, survival, and virulence continue to be investigated.

Case Presentation
A 37-year-old man with a past medical history of acute monocytic leukemia (AML),
hypertension, and type II diabetes mellitus presented to the hospital with worsening chills, diffuse muscle aches, increased drainage from mouth sores, subjective fevers, and increasing fatigue six days after completing a 7+3 chemotherapy regimen with daunorubicin/cytarabine. The patient had gingivostomatitis predating his official AML diagnosis. Febrile neutropenia was suspected due to the patient&#39;s symptoms and pancytopenia with prolonged and profound neutropenia. Blood cultures from admission grew E. faecalis repeat blood cultures were negative, and no aerobic bacteria were visualized. Respiratory cultures, Legionella antigen, rapid influenza A and B, and COVID-19 PCR tests were all negative. The patient was initially
empirically treated with cefepime, then switched to piperacillin/tazobactam. When
susceptibilities from the initial blood culture showed that E. faecalis was pan-sensitive, the patient was discharged on an oral regimen of amoxicillin for 14 days. Repeat blood cultures were negative within 48 hours of discharge. A transthoracic echocardiogram showed no evidence of vegetations, and there was low suspicion for infective endocarditis.

Discussion
There have been few documented cases of E. faecalis associated with underlying colorectal malignancies and the development of infective endocarditis. However, there are no documented cases where E. faecalis was identified in the bloodstream and treated before complications (e.g., infective endocarditis) developed. The scarcely documented cases of pan-sensitive E. faecalis make this case unique. The translocation of E. faecalis from the GI tract to the bloodstream is possibly more likely during induction chemotherapy with daunorubicin and cytarabine, which damage the gastrointestinal epithelium and cause painful oral mucositis and diarrhea. In combination with the neutropenia induced by this treatment, it is very likely that this patient’s AML chemotherapy regimen led to his E. faecalis infection. The feasibility of gut-protective measures during intensive chemotherapy induction to reduce translocation of gastrointestinal infections is an area needing further investigation. The patient’s rapid recovery from this infection and its pan-susceptibility is unusual and resulted in an excellent outcome.

AMA Research Challenge 2024 

Blood Stream Invasion: Enterococcus Faecalis Takes a Wild Gut Trip in a Neutropenic
Environment

Background
Enterococcus faecalis (E. faecalis) is a well-known bacterium that colonizes the human gastrointestinal (GI) tract. It is most recognized for causing antibiotic-resistant bacteremia, pneumonia, intra-abdominal infections, and endocarditis. Overgrowth in the gut and translocation to the bloodstream through the intestinal epithelium is the widely accepted mechanism for developing E. faecalis bacteremia, although the mechanisms of invasion, survival, and virulence continue to be investigated.

Case Presentation
A 37-year-old man with a past medical history of acute monocytic leukemia (AML),
hypertension, and type II diabetes mellitus presented to the hospital with worsening chills, diffuse muscle aches, increased drainage from mouth sores, subjective fevers, and increasing fatigue six days after completing a 7+3 chemotherapy regimen with daunorubicin/cytarabine. The patient had gingivostomatitis predating his official AML diagnosis. Febrile neutropenia was suspected due to the patient's symptoms and pancytopenia with prolonged and profound neutropenia. Blood cultures from admission grew E. faecalis repeat blood cultures were negative, and no aerobic bacteria were visualized. Respiratory cultures, Legionella antigen, rapid influenza A and B, and COVID-19 PCR tests were all negative. The patient was initially
empirically treated with cefepime, then switched to piperacillin/tazobactam. When
susceptibilities from the initial blood culture showed that E. faecalis was pan-sensitive, the patient was discharged on an oral regimen of amoxicillin for 14 days. Repeat blood cultures were negative within 48 hours of discharge. A transthoracic echocardiogram showed no evidence of vegetations, and there was low suspicion for infective endocarditis.

Discussion
There have been few documented cases of E. faecalis associated with underlying colorectal malignancies and the development of infective endocarditis. However, there are no documented cases where E. faecalis was identified in the bloodstream and treated before complications (e.g., infective endocarditis) developed. The scarcely documented cases of pan-sensitive E. faecalis make this case unique. The translocation of E. faecalis from the GI tract to the bloodstream is possibly more likely during induction chemotherapy with daunorubicin and cytarabine, which damage the gastrointestinal epithelium and cause painful oral mucositis and diarrhea. In combination with the neutropenia induced by this treatment, it is very likely that this patient’s AML chemotherapy regimen led to his E. faecalis infection. The feasibility of gut-protective measures during intensive chemotherapy induction to reduce translocation of gastrointestinal infections is an area needing further investigation. The patient’s rapid recovery from this infection and its pan-susceptibility is unusual and resulted in an excellent outcome.

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Introduction: 
Aortic calcification is a significant pathological process associated with various cardiovascular diseases. While the sympathetic nervous system's influence on bone remodeling via β2-adrenergic receptors (β2-ARs) is well-established, its impact on vascular calcification remains relatively unexplored. Previous research suggests β2-ARs play a critical role in regulating valve calcification but have yet to be studied in aortic calcification. Thus, we aim to characterize the expression patterns of both β1-ARs and β2-ARs to elucidate the downstream signaling mediators in human aortic tissue and determine the effects of selective β2-AR agonists on aortic smooth muscle cell phenotype and function. 

Methods: 
Calcified and non-calcified abdominal aortic wall segments from 6 patients with abdominal aortic aneurysm (AAA) were collected during elective open aortic repair at Northwestern Memorial Hospital (Chicago, IL). Samples were fixed, decalcified, and embedded in paraffin. Sections of 5 μm thickness were used for immunostaining of alpha-smooth muscle actin, β1-AR, and β2-AR. Human aortic smooth muscle cells (HAoSMC) were cultured in osteogenic media and treated with one of the following β-AR agonists (1 - 100 μmol/L): salmeterol, isoproterenol, norepinephrine, or an antagonist (0.3 – 30 μmol/L): ICI-118,551 or CGP-20712A. Cells were fixed for immunocytochemical staining of osteogenic markers (osteocalcin, osteopontin, and Runx2) and β-ARs. HAoSMCs were treated with salmeterol (1 μmol/L, β2-AR agonist) in the presence of either growth media or osteogenic media for up to 14 days. Metabolic and alkaline phosphatase (ALP) activity were measured with resazurin (n=8) and ALP assays (n=3), respectively, on days 7 and 14. 

Results: 
Samples of abdominal aortic wall segments show differential expression of β2-adrenergic receptors between patients with abdominal aortic aneurysms. Culturing human aortic smooth muscle cells (hAoSMCs) in osteogenic (OST) media for 21 days successfully induced an osteogenic phenotype as evidenced by increased alkaline phosphatase (ALP) activity over time. Delivery of β2 agonist salmeterol to human aortic smooth muscle cells cultured in both growth media and osteogenic media showed no significant difference in metabolic activities after 21 days. Osteogenic cells treated with salmeterol demonstrate less alkaline phosphatase activity at day 21. Osteogenic differentiation of human aortic smooth muscle cells downregulates β2-adrenergic receptor expression. Stimulation of osteogenic smooth muscle cells with a β2 agonist, salmeterol, further downregulates receptor expression. Osteopontin expression decreased in osteogenic human aortic smooth muscle cells treated with salmeterol.

Conclusions: 
We observed a differential expression of β2-ARs across sections of human calcified aortas, suggesting a role of these receptors in areas subjected to different calcific stresses. In vitro experiments also demonstrated an impact on the calcification process. Further in vitro experiments with HAoSMCs treated with β-AR agonists and antagonists will help to elucidate the influence of β-adrenergic signaling on vascular calcification pathways. 


Characterization of Beta-Adrenergic Receptors in Human Aortic Abdominal
Aneurysm Tissue and Human Aortic Smooth Muscle Cells

Background
Longitudinal symptoms monitoring is challenging, which hinders supportive care delivery, quality improvement, and research efforts. Over half of oncology patients’ emergency department visits are preventable, many caused by symptom exacerbations. Patient conversations contain valuable information about symptoms, but this data is not well-captured in medical documentation. The combination of Large Language Models (LLMs) and ambient audio recording technology could enable robust monitoring of patient symptoms from clinical conversations, surpassing traditional NLP techniques. While there are various benchmarks to assess LLMs in medical question answering, there is a lack of standardized benchmarks to evaluate their performance in real-world symptom detection use cases. This study aims to test the performance of four LLMs to capture symptoms discussed in transcribed conversations from standardized clinical encounters.
Methods 
This study demonstrates a novel methodology for evaluating LLMs on their ability to extract symptoms from published simulated patient conversations. We created a gold standard, double-coded transcript dataset (n=264) annotated for 16 specific symptoms plus a catch-all ‘other’ category. Four models (GPT 3.5 turbo, GPT-4, GPT-4 turbo, and GPT-4o) were assessed on the quality of their zero-shot symptom extractions. Models were evaluated for task performance (precision, recall, accuracy, F1 score). Statistical significance was calculated using Cochran's Q, followed by pairwise post hoc McNemar tests with a Bonferroni correction. 
Results 
3,085 transcript excerpts were annotated for presence or absence of symptoms. 2,087 excerpts contained symptoms which were further annotated for 16 symptoms of interest. The three most common symptoms were pain, cough, and shortness of breath. GPT-4 showed the highest overall performance for symptom talk detection F1=0.94 (p<0.05). Detection of the three most common symptoms achieved F1 scores ranging from 0.74 to 0.89 across models. 
Conclusion
We developed a patient transcript benchmarking dataset for symptoms and demonstrated LLM evaluation using this dataset. This study highlights the effectiveness of GPT-4 in symptom detection, showing the best overall performance among the four evaluated models (p<0.05). The high F1 scores achieved for detecting the three most common symptoms (pain, cough, and shortness of breath) across models support the potential of LLMs in clinical NLP tasks. As LLM- based data extraction is institution-agnostic, these models may provide a more generalizable and transferable approach to challenging NLP tasks in healthcare. Future research includes exploring benchmarking on real patient data and practical considerations of implementing LLM-augmented symptom tracking into current workflows.

Development of a Benchmarking Dataset for Symptom Detection Using Large Language Models

Efficacy of Osteopathic Manipulative Treatment on Headache Frequency and Intensity in Patients with Tension-Type Headaches: A Systematic Review and Meta-analysis
Fadia Barakzai, Arwa Khadr, Heba Farhan 

Introduction: Tension-Type Headache (TTH) is one of the most common types of headache with a prevalence of 38.2%.1 TTH is defined as the presence of a pressing and bilateral sensation with mild to moderate pain intensity.2 The pain is in a band-like fashion from the forehead to the occiput.3 Age of onset for TTH is between 20-23 years old and common triggers include sleep disturbances and stress.3 TTH lasts for about 30 minutes to 24 hours and does not typically accompany photophobia, or aura.3 TTH is commonly self-treated with over the counter medication such as NSAIDs, and analgesics.3,4 Overuse of NSAIDs have been shown to have many side effects such as, acute kidney injury (AKI) and upper gastrointestinal peptic ulcer disease and bleeding.5,6 Osteopathic Manipulative Treatment (OMT) have shown to improve headaches by correcting the somatic dysfunction through releasing myofascial and structural restrictions and improving lymphatic flow.7
Objective: to assess the efficacy of OMT versus control in the treatment of TTH for reducing headache frequency and intensity.

Methods: This systematic review and meta-analysis was conducted utilizing the PRISMA 2020 guidelines (Figure.1).8 Electronic search was conducted through PubMed, Embase, Scopus, Cochrane, and Web of Science. Relevant articles published from inception until June 10, 2024, were searched using a combination of keywords and medical subject heading (MeSH) terms, including “tension headache”, “frequency”, “intensity”, and “OMT”. Mean and standard deviation were extracted to perform a random-effects meta-analysis using SPSS. Primary outcomes included headache frequency and intensity. Secondary outcomes included quality of life, and over the counter medication use. Inclusion criteria were RCTs comparing OMT to control for the treatment of TTH. Articles that did not involve OMT or the relevant headache type were excluded. Non-randomized trials and duplicate studies were also excluded.

Results: The number of days with headache per month decreased by 6.2 (2.4) [mean (SD)] days in the OMT group compared to 2.8 (0.7) days in the control group, (p= 0.01). The mean difference in frequency reduction was 4.2 days (95% CI = 3.1 to 5.3, p < 0.001). There was no difference in headache intensity between OMT and control groups. The mean difference in headache intensity reduction was 0.6 points (95% CI = -0.3 to 1.4, p = 0.10). A reduction in medication use was observed in the OMT group compared to control (MD = -1.88, 95% CI = -1.93 to -1.11, p = .001). Patients receiving OMT reported improved quality of life scores (MD = 1.81, 95% CI = 0.89 to 4.01, p = .02) compared to control.

Discussion: OMT significantly reduced headache frequency although it did not statistically show improvement in headache intensity. The overall decrease in the occurrence of headaches after OMT suggests that OMT is an effective treatment intervention for TTH. OMT for TTH significantly reduced the use of OTC medications which suggest that OMT can be used as a non-pharmacological approach to headache management. This can reduce the dependence on OTC medications for symptom relief and it can reduce the side effects associated with the use of some OTC medications. OMT significantly improved the quality of life for patients with TTH. This suggests that OMT addresses both the physical and psychological aspects of a patient’s life. 

Conclusions: OMT is an effective treatment intervention for TTH. OMT significantly reduced headache frequency, improved quality of life, and reduced over-the-counter medication use in patients suffering from TTH. OMT did not have a significant effect on headache intensity. Additional RCTs are needed to confirm these findings and inform clinical practice. 

References 
1.Cerritelli F, Lacorte E, Ruffini N, Vanacore N. Osteopathy for primary headache patients: a systematic review. J Pain Res. 2017;10:601-611. Published 2017 Mar 14. doi:10.2147/JPR.S130501
2.Ashina S, Mitsikostas DD, Lee MJ, et al. Tension-type headache. Nat Rev Dis Primers. 2021;7(1):24. Published 2021 Mar 25. doi:10.1038/s41572-021-00257-2
3. Onan D, Younis S, Wellsgatnik WD, et al. Debate: differences and similarities between tension-type headache and migraine. J Headache Pain. 2023;24(1):92. Published 2023 Jul 21. doi:10.1186/s10194-023-01614-0
4. Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician. 2002;66(5):797-804.
5. LaForge JM, Urso K, Day JM, et al. Non-steroidal Anti-inflammatory Drugs: Clinical Implications, Renal Impairment Risks, and AKI. Adv Ther. 2023;40(5):2082-2096. doi:10.1007/s12325-023-02481-6
6. Tai FWD, McAlindon ME. Non-steroidal anti-inflammatory drugs and the gastrointestinal tract. Clin Med (Lond). 2021;21(2):131-134. doi:10.7861/clinmed.2021-0039
7.Whalen J, Yao S, Leder A. A Short Review of the Treatment of Headaches Using Osteopathic Manipulative Treatment. Curr Pain Headache Rep. 2018;22(12):82. Published 2018 Oct 5. doi:10.1007/s11916-018-0736-y
8. Haddaway, N. R., Page, M. J., Pritchard, C. C., & McGuinness, L. A. (2022). PRISMA2020: An R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis Campbell Systematic Reviews, 18, e1230. https://doi.org/10.1002/cl2.1230

Efficacy of Osteopathic Manipulative Treatment on Headache Frequency and Intensity in Patients with Tension-Type Headaches: A Systematic Review and Meta-analysis


INTRODUCTION & BACKGROUND: 

The hepatic hilum includes the hepatic arterial supply, portal venous system, and hepatic bile ducts, which all vary in measurements and branching pattern. The complete hepatic vasculature consists of the common hepatic artery (CHA), proper hepatic artery (PHA), right hepatic artery (RHA), left hepatic artery (LHA), cystic artery (CA), and gastroduodenal artery (GDA). The arterial length and diameter have significant implications for liver transplants, liver resections, and hepatobiliary surgeries. In this study, measurements were taken of the entire hepatic arterial vasculature originating from the celiac trunk (CT) to investigate the vessels’ respective diameters and lengths. 

HYPOTHESIS: 

The measurement of variations in the length and diameter of the hepatic vasculature will contribute to existing literature and the associated hepatic clinical implications. 

METHODS: 

Data collection and dissection were performed at Tilman J. Fertitta Family College of Medicine and Baylor College of Medicine. Thirty-six cadaveric samples were dissected at the hilum of the liver along with the surrounding vasculature. The CHA measurement extended from the CT's origin to the bifurcation of the CHA. The PHA was measured beginning at the CHA bifurcation to the point of PHA bifurcation. Measurement of the GDA began at its branch point from the CHA to the Anterior Superior Pancreaticoduodenal Artery. Both the RHA and LHA were measured at the bifurcation origin point to their segmental intrahepatic branching. The CA was measured from its branching point off of the RHA to the termination point on the gallbladder. A vernier caliper was used to measure all vasculatures’ lengths and their respective external diameters. 

RESULTS: 

In thirty-six cadaveric samples, the mean distance between the CT and the CHA was 33.44 mm, with a diameter of 8.88 mm, an increase compared to other studies. The mean length of the PHA was 21.53 mm, with a diameter of 5.98 mm. The LHA measured a mean of 30.39 mm in length and 3.97 mm in diameter, revealing no substantial differences compared to other studies. The RHA had a mean length of 29.65 mm and a mean diameter of 4.76 mm. The GDA averaged 32.33 mm in length and 4.34 mm in diameter. Lastly, the CA had a mean length of 24.01 mm and a diameter of 2.33 mm. 



DISCUSSION/CONCLUSION: 

Understanding these measurements and variations in arterial anatomy can provide specific guidance and enhance safety in surgeries such as liver transplants, which are particularly vulnerable to complications like intraoperative bleeding and necrosis. Moreover, knowledge of the expected values of arterial diameter and length can contribute to hemodynamic data, potentially assisting in the early diagnosis of arterial stenosis. Further, small arterial caliber is known to contribute to hepatic artery thrombosis. Our study's findings give insight into the distances and diameters of hepatic vasculature and its tie to hepatic clinical implications.

Evaluation of Hepatic Arterial Vasculature and the Implications for Hepatic Surgery – A Cadaveric Pilot Study

Introduction
Emergent endovascular abdominal aortic aneurysm repair (EVAR) in ruptured or symptomatic patients is often performed in patients with sub-optimal aortic anatomy. Our aim was to assess outcomes of emergent EVAR in patients with various neck morphologies.

Methods
Using the Vascular Quality Initiative, we conducted a retrospective review of patients who underwent EVAR from 2003-2023. We categorized patients by urgency (elective, symptomatic, ruptured) and neck morphology (short/narrow, short/wide, long/narrow, long/wide), excluding patients with incomplete data. Neck length under 15mm was short; neck diameter over 28mm was wide. Primary outcomes were Type 1A endoleaks and conversion to open repair. Secondary outcomes were AAA sac diameter change and short- and long-term mortality. Multivariable logistic regression was used to assess the relationship between neck group (long/narrow as reference group) and each primary outcome, controlling for demographic factors and presence of type 1B endoleak for each urgency setting separately. 

Results
78,239 patients underwent EVAR: 66,313 (84.76%) elective, 7,055 (9.02%) symptomatic, 4,871 (6.2%) ruptured. 30,912 patients had data on urgency and neck anatomy. Average age was 73 years. 81.4% were male.
In multivariable analysis, symptomatic patients with short/wide (OR3.43 p=0.0016) and short/narrow (OR2.75 p<0.0001) necks had increased odds of Type 1A endoleak; in ruptures, short/narrow necks (OR3.32 p=0.0002) had higher odds. Conversion to open repair was higher in rupture (2.91%) than symptomatic (0.5%) and elective (0.3%). Conversion was not significantly associated with neck group in any setting. 
Symptomatic patients had a median decrease of 6mm in sac diameter (range -89 to +46mm) at median follow up of 413 days. At median follow-up of 403 days, patients with ruptured aneurysms had a median sac diameter decrease of 11mm (range -107 to +62mm). There was no significant difference in sac diameter change between neck groups (p>0.05).
Patients with ruptures and short/narrow necks had lowest survival probability while those with long/narrow necks had highest survival probability at one year (63.75 vs 74.86%, respectively; p<.0001).

Conclusion
Neck morphology remains an important factor in outcomes of EVAR performed in emergent settings. In symptomatic and ruptured aneurysms undergoing EVAR, short/narrow necks performed the worst with increased rates of Type 1A endoleaks and decreased survival.

Impact of Neck Morphology on Outcomes of Emergent Endovascular Aneurysm Repair

The opioid epidemic has adversely affected neonates and children; but the scope and mechanisms of these affects are not well understood. Failure to understand the impact of prenatal opioid exposure on long term adverse health outcomes could lead to gaps in care for this population. The purpose of this study is to investigate the association of prenatal opioid exposure with the development of adverse respiratory health outcomes, both acute and chronic. We propose that prenatal exposure leads to increased odds of development of childhood asthma, respiratory distress, apnea, and bronchiolitis. This is a retrospective cohort study using the PearlDiver Mariner database and a simple match design. Records from preterm and full-term infants exposed to opioids in utero are analyzed separately for the development of adverse health outcomes. Our preliminary results indicate that opioid exposure in utero results in preterm birth. In full-term infant births, opioid exposure leads to increased odds for developing respiratory distress (OR = 7.54), bronchiolitis (OR = 4.12) and apnea (OR = 1.58). Lastly, diagnoses for adverse respiratory outcomes were earlier in full-term opioid exposed infants than in their unexposed controls. The significance of this study is that it will encourage closer monitoring of full-term infants who are exposed to opioids in utero for specific respiratory outcomes and provide conceptual grounding for future mechanistic studies.



Prenatal opioid exposure impacts respiratory outcomes within the first 5 years of life

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers
Ishita Gupta Kaushal, Arshdeep Singh, Le Yen Ly Nguyen, Pragti Garg, Raziullah Riaz, Ajaybir Singh Buttar, Chandan Sona Bevara,Youngsang You, Ansa Ali, Onkardeep Kaur, Aparna Malireddi, Ratesh Khillan MD

Background
Mucosal melanoma of the oral cavity (MMO) constitutes less than 1% of all melanomas. The majority of MMO occur in upper alveolus and hard palate (70%) followed by lower alveolus. The etiology, risk factors and pathogenesis for MMO are poorly understood. Patients with MMO can present with bleeding, local discoloration, facial pain, ulceration, with localized swelling being the most common. Due to the diversity of initial symptoms and histological pleomorphism, immunohistochemical staining is crucial to confirm the diagnosis. Mucosal melanoma (MM) has a very poor prognosis and most patients develop incurable metastatic disease, irrespective of surgical excision.
Due to poor prognosis, staging starts from T3 for lesions confined to mucosa and adjacent soft tissue and T4 for moderately advanced and very advanced lesions, as recommended in 8th edition of AJCC. For tumors limited to mucosa, NCCN recommends postoperative radiotherapy within 6 weeks of resection with consideration for systemic therapy.
In this study, we present a unique case of a 64-year-old Hispanic female with multiple recurrences of MMO.

Case presentation
A 64-year-old Hispanic female presented to our clinic with a possible recurrence of malignant melanoma of hard palate. It started as an irregularly shaped discoloration of gums and the hard palate. She underwent 3 surgical resections in her home country. Adjuvant chemo and radiotherapy were recommended, which proved to be financially challenging.
On presentation to our clinic, she had a tender bluish patch approximately 1 cm in diameter with ulcers on hard palate and a soft bluish bumpy left upper gum lesion approximately 1 cm in diameter, which bled on touching. Following the punch biopsies and various radiographic studies, left maxillectomy was done, the pathology report and immunohistochemistry of which confirmed stage ypT3N0 residual malignant melanoma. Again, patient could not undergo adjuvant chemo and radiotherapy due to financial constraints.

Discussion
Due to the condition’s rarity, rapid progression, and hence delayed diagnosis and poor prognosis, it is essential to complete the treatment regimen, which includes surgical resection followed by chemo and radiotherapy. This case shows the inequitable distribution of medical resources in patients with low socioeconomic status. The lack of medical insurance can hinder patient care in basic cancer treatment like surgery and radiotherapy. This issue is of even greater relevance in the treatment of cancer which is rapidly debilitating and fatal. Even in instances of potentially curable cancers, socioeconomic status, lack of available therapies and cultural stereotypes can impede treatment.

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers

Background:
Dog bites are a well-known mode of transmission for Capnocytophaga canimorsus. However, patients rarely present with meningitis. The few reported individuals experience high fevers and have concerning rates of neurological sequelae upon recovery. Common risk factors include a compromised immune system, alcoholism, and animal exposure. Although most patients recover with sufficient antibiotic treatment, the selected course varies widely. Here, we present an unusual case of brain infarction and subarachnoid hemorrhage in addition to Capnocytophaga canimorsus meningitis.

Case Presentation:
A 74-year-old man with history of seizures, hypertension, and smoking presented to our hospital with a one-day history of malaise and after being found unresponsive by his wife. Upon arrival to the hospital, he was found to have seizures, a high fever of 39.1°C, and hypoxemia requiring 4 L of oxygen via nasal cannula. The patient received levetiracetam, ceftriaxone, and vancomycin. Lumbar puncture was performed and yielded cloudy cerebrospinal fluid (CSF) with a WBC count of 1185 cells/mm3 (98% polymorphonuclears), glucose of 9 mg/dL, and protein of 417 mg/dL. Gram stain revealed gram-negative bacilli, and the culture showed Capnocytophaga canimorsus susceptible to ceftriaxone (MIC 0.25), with low MICs for ciprofloxacin, meropenem, and penicillin. Brain MRI showed multiple embolic infarcts and subarachnoid hemorrhage. Transthoracic echocardiogram showed no vegetations. The patient was treated with 4 weeks of intravenous ceftriaxone and clinical follow up showed clinical improvement after antibiotic treatment.

Discussion:
In the case presented, this individual required longer antibiotic treatment than the reported median of 15 days. Of the three prior reported cases with acute brain infarction during infection, two had lingering neurological issues and also required bilateral lower extremity amputation. A hyperinflammatory state, vasospasm, and activation of the coagulation cascade have all been hypothesized to contribute to the association between bacterial meningitis and cerebral infarction. This known complication in meningitis has severe repercussions for the long-term recovery of patients. Prompt recognition and treatment is vital to limb salvage and optimal neurological recovery.

A rare case of Capnocytophaga canimorsus meningitis with acute cerebral infarct and subarachnoid hemorrhage

Introduction:
Klebsiella pneumoniae is a well-described etiology of pyogenic liver abscess (PLA) in patients from Southeast Asia, but rarely outside of that region. We present a rare case of Klebsiella PLA in Eastern Long Island in a patient with no travel history to Southeast Asia.

Case Presentation:
A 71-year-old Puerto Rican male with PMH diabetes, hepatitis C s/p treatment presented with dull, non-radiating right lower quadrant pain associated with non-bloody non-bilious vomiting and intermittent fevers for 2 weeks. He denied other previous gastric or hepatobiliary disease or malignancy, abdominal trauma/surgeries, alcohol use, IV drug use, history of pancreatitis or liver transplant, PPI use, or any travel history in the last 15 years. On examination, T 102.8°F, BP 126/86, HR 96, RR 27, SpO2 99% on RA; he had tenderness in the right lower quadrant. Labs showed normal WBC and hepatic function, and mildly elevated alkaline phosphatase at 142. CT abdomen/pelvis with oral and IV contrast showed a liver mass (Figure 1). Subsequent MRI abdomen with and without IV contrast (Figure 2) demonstrated a 6.1 x 6.9 x 6.9 cm posterior right hepatic lobe abscess. He was admitted for sepsis secondary to liver abscess and started on broad-spectrum antibiotics. The abscess was drained and fluid culture subsequently grew Klebsiella pneumoniae. The patient improved clinically during the remainder of the hospitalization and was discharged on four weeks of oral levofloxacin.

Discussion:
Pyogenic liver abscesses (PLA) are pus-filled masses that can develop after hematogenous spread from an intraabdominal infection, bacteremia, or nearby liver injury. The incidence of pyogenic liver abscess is about 2.3 cases per 100,000 people and has been well-described in Southeast Asia – especially in Taiwan. Klebsiella pneumoniae PLA has been reported in Taiwan since the 1980’s with more than 900 cases identified, as compared to only 50 cases in Western countries from the 1990’s to early 2000s. In another extensive literature review, only 93 cases were found in the United States from 1949 to 2016. 80% of PLA cases found Klebsiella pneumoniae as the predominant bacteria, as compared to non-Eastern Asian countries, where E. coli and Streptococcus species predominate. Risk factors include diabetes, history of hepatobiliary infection or colorectal cancer, abdominal trauma or surgeries. Clinical features include fever, right upper abdominal, nausea and vomiting. Labs may show leukocytosis, hyperbilirubinemia, elevated ALP/ AST. MRI with IV contrast is the most sensitive study. Treatment involves drainage and antibiotic therapy, with good prognosis.

Conclusion:
Clinicians should keep rare etiologies in mind for patients who present with liver abscesses.


But I Never Went to Southeast Asia! A Rare Case of Klebsiella penumoniae Pyogenic Liver Abscess in Eastern Long Island

Fournier's gangrene (FG) is an uncommon and life-threatening necrotizing fasciitis affecting the perineum and genital region. This condition typically involves polymicrobial infection of the deep soft tissues and fascial planes. FG occurs more frequently in diabetic patients due to impaired immune function, hyperglycemia, microvascular complications, peripheral neuropathy, or genital and urinary infections. In this case, it is observed that it can also develop in a non-diabetic individual, presenting a considerable diagnostic and treatment challenge.

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