United States

Background: The Achilles Tendon is difficult to visualize because it yields a low signal-to-noise ratio that precludes MRI visualization. While ultrasound yields competent qualitative images, it provides limited quantitative measures. Recent studies, however, have shown aligning the Achilles at a 55-degree angle to the MRI’s primary axis, denoted “the magic angle,” boosts signal-to-noise ratio. Wengler et al., applied diffusion tensor imaging (DTI), an MRI measure that creates images by leveraging the movement of water, to visualize and quantify diffusivity within the Achilles tendons of participants. This paper promoted DTI as a visualization tool for Achilles pathologies, and we further built upon its findings by studying whether DTI yields reproducible results.

Methods: Participants (n=10) with healthy Achilles were included. The right Achilles was imaged in an MRI with the ankle placed at a 55-degree angle relative to the magnet in a 3T MRI. 6-mm transverse slice images were obtained with the following parameters: 1 mm2 isotropic resolution, 2 signal averaging, 5000/58 ms repetition/echo times, 500s/mm2 diffusion strength, 30 gradient directions, and 5 mins scan time. Participants were then given a 5–10-minute break and had the same Achilles re-imaged, following the same steps as before. The MRI images were post-processed with DSI Studio, an open-source diffusion analysis software (http://dsi-studio.labsolver.org). Fractional anisotropy (FA) along with mean (MD), radial (RD), and axial diffusivity (AD) were measured, and reliability was assessed by visualizing Bland-Altman plots. Scan and rescan values were averaged within-participant and mean (SD) were reported for the group. Average differences between scan and rescan values are also reported descriptively.

Results: Average diffusivity of scan and rescan images were, FA: (mean (SD)) 0.419(0.092); RD: 0.893(0.304) mm2/s; AD: 1.663(0.545) mm2/s; and MD: 1.150 (0.371) mm2/s. Average difference between scan and rescan were, FA: 0.008(0.072); RD: 0.075(0.267) mm2/s; AD: 0.114(0.455) mm2/s; and MD: 0.088 (0.323) mm2/s. Bland-Altman plots showed the difference between each scan and rescan was within 95% confidence interval for all four diffusivity measures.

Conclusion: Our preliminary study demonstrates that DTI of the AT produces results that are unbiased (bias less than 10% for all metrics), however, consistency between values suggests the need for further optimization (30% inconsistency between scans).

AMA Research Challenge 2022

Preliminary Reproducibility Analysis of Diffusion Tensor Imaging of the Achilles Tendon

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Abstract Title: Qualitative Interviews with Primary Care and Gynecological Providers about Obesity Treatment 

Matta K, McCabe C, Bailey-Davis L

Background

To reduce the rates of obesity, the United States Preventive Services Task Force (USPSTF) guidelines recommend that clinicians offer/refer any patient with a BMI of 30 kg/m2 or higher to an intensive, multicomponent behavioral intervention. Despite this recommendation, obesity remains a pervasive concern. The purpose of this study was to evaluate the perceived use of USPSTF guidelines in treating obesity by community medicine physicians (CMPs) and gynecologists. The 5 A’s model (e.g., assess, advice, agree, assist, and arrange) was used to organize the process of obesity treatment.

Methods

Semi-structured interviews of CMPs and gynecologists at Geisinger Health were conducted in March-May 2022. Telephone interviews were completed by trained interviewers using an internal service that transcribed the data verbatim. The study team reviewed the transcripts independently in their entirety to identify initial codes using an open coding approach. These preliminary codes were then organized using the 5 A’s model for obesity treatment as themes. Data were further divided into the subthemes of “facilitators,” “barriers,” or “existing” practice within each 5 A theme.

Results

Recruitment response was 36%; 22 physicians contacted, 4 gynecologists and 4 CMPs were interviewed. Overall, physicians indicated that assessment and advice were routinely practiced and aligned with guidelines but agree, assist, and arrange were areas of weakness. By each A, the facilitators include: Assess: medical jargon in conversation Advice: personalizing advice; Agree: shared-decision making about referrals; Assist: none; and Arrange: specialty referrals. Conversely, barriers include: Assess: patient discomfort; Advice: lacking education; Agree: none; Assist: anti-obesity medications; Arrange: referrals out of Geisinger/referral results.


Conclusion

Physicians are adopting practices to advance Agreement, perceive barriers to Assisting and Arranging, and although Assessment and Advice were commonly practiced, there is discomfort with starting conversations and management strategies. These findings are mixed relevant to prior 5 As research. Our finding that Assess and Advice are practiced and that physicians struggle with the Assist and Arrange is consistent, however greater facilitation of Agreement is novel. These findings are useful for understanding why obesity treatment practices are not aligned with the guidelines, and where improvements could be made to support physicians and patients.

Qualitative Interviews with Primary Care and Gynecological Providers about Obesity Treatment

Background
The literature finds that 70% of transgender people report healthcare discrimination, along with radically increased rates of MDD, AUD, SI, SA, and mental illness. 41% self-reported a history of SA, with nonaccess to gender-affirming surgery equating a 71% higher odds.

Case Presentation
Joshua, a 16 year-old transgender male, using he/him/his pronouns, with no known psychiatric history, was admitted to the children's hospital for intentional Tylenol overdose, presenting with severe abdominal pain, somnolence, and nonbilious emesis, with elevated LFTs and INR, but metabolic panel and CBC otherwise within normal limits. The patient was promptly treated with N-acetylcysteine, showing improved alertness the next day, along with quiet but appropriate affect and mood. The patient admitted to two years of depression and two suicide attempts. Inpatient PHQ-9 was 29. Joshua reported a supportive household, but consistent bullying and misgendering at school, with peers and teachers refusing to use his chosen name and continuing to refer to him as “a girl”, harassing him any time that he uses male restrooms. Joshua has never followed with a psychiatrist or received gender-affirming treatment, but desires hormone therapy. While inpatient, Joshua's senior resident was adamant that she and her team use Joshua's chosen name and consistently use male pronouns, presenting Joshua as a "16 year-old male". 

Discussion
The hospital used a standard EMR, allowing for SOGIE data to be put into charts, but not allowing names or genders to be changed. The team was intentional about using accurate pronouns and Joshua's chosen name in documentation, and on a virtual "post-it". However, when running the list at the end of the day, the senior resident incorrectly named Joshua as "Allison", misgendering him. Despite the team's efforts, this was the name and sex printed from the EMR.

A survey of 204 transgender children found an overwhelming preference to use their chosen names in documentation, even when considering safety concerns. Even when SOGIE data is available, it is rarely automated into documentation. This case study presents a common barrier to affirmative care for transgender patients through limits in the EMR, necessitating a conscious effort by providers and recognition of their shortcomings.

Barrier to Care for Gender Minority Patients

Background:
Miliary TB is an aggressive infection in the setting of lymphohematogenous distribution of the bacilli of M. tuberculosis, that can be potentially fatal if left untreated. Drug-resistant TB may occur in the setting of patient non-compliance, concomitant HIV infection, inability to receive the correct duration and dose of medications, or patients in high-risk areas such as China or India.

Methods:
We describe a young immigrant patient who presented with electrolyte derangement and was found to have a complicated combination of infections including acute disseminated miliary TB, syphilis, and HIV. Our goal is to discuss this rare case and address risk factors associated with his immigrant status and barriers to treating these three serious infections together.

Results: 
A 33 YO Hispanic M immigrant from Mexico with PMH of prior COVID-19 infection presented with cough, fever, and weakness. He was tachycardic and tachypneic with sufficient oxygen saturation on room air. Labs demonstrated hypoNa of 122mEq/dL (ref range 135-145) and he was admitted to the MICU for severe electrolyte derangement. CXR showed R lobe infiltrates. CT CAP suggestive of diffuse disseminated TB with severe PNA and several cavitary lesions involving the mediastinum. Sputum AFB cultures were positive. ID and Pulmonology teams were consulted and the patient began RIPE therapy. Admission was complicated by diagnoses of HIV and Syphilis. HAART therapy was deferred and the patient received Penicillin injections for Syphilis as well as prophylactic Bactrim DS (CD4 count 57). HypoNa improved and the patient was transferred to the floors. Despite >20d of RIPE therapy and the patient remaining asymptomatic, he remained AFB sputum culture positive, attributed to his concomitant HIV status or drug resistance.

Conclusion:
A high prevalence of HIV, syphilis, and TB exists in immigrant populations. It is imperative to screen for rapid diagnosis and management. Given high mortality rate of miliary TB, initiation of RIPE therapy is essential. Our patient’s HAART initiation was held to prevent immune reconstitution syndrome in the setting of multiple infections. There is limited randomized control trial data regarding optimal treatment guidelines and duration for patients with drug-resistant TB, especially with concomitant HIV.

Disseminated Miliary Tuberculosis with Drug Resistance & Concomitant Syphilis & HIV Infections

The risk of assumptions when approaching abdominal pain

Introduction
In the summer of 2022, the Rainy River Basin in Northern Minnesota and nearby Ontario Canada experienced historic flooding with the highest levels in over 70 years, and with water levels peaking on June 15th. This flooding caused unusually large amounts of standing water in the region and resulted in an atypical year for mosquitos in the region, particularly the Summer Floodwater mosquito, or Aedes vexans.

Mosquito bite hypersensitivity is characterized by edema and skin reactions. There are some known causes of hypersensitivity reactions to mosquito bites. Epstein Barr Virus, natural killer (NK) cell lymphocytosis, and chronic urticaria are conditions known to be associated with mosquito hypersensitivity. Children with atopy, and grass allergies are more likely to have mosquito hypersensitivity. However, the exact cause of these associations is unknown.

Methods
We observed mosquito bite reactions in a camp of 108 campers and 52 staff located in the Rainy River Basin, and with wilderness trips throughout Northern Minnesota and Southern Ontario, Canada. We tracked reactions throughout 3.5-week sessions for campers and over 9 weeks for staff.

Results
Unusual hypersensitivity reactions were observed in the Rainy River Basin near Rainy Lake at a sleep away summer camp among staff and campers. These reactions were indicative of allergic reactions or “skeeter syndrome.” Skeeter syndrome is a rare allergic and often severe allergic reaction to mosquito bites resulting in blistering and swelling at the site of the bite, and in less severe cases bruising. Reactions that were observed at the camp included periorbital edema, ulcerative lesions, blistering, and ecchymosis. One case in particular resulted in swelling at the joint of multiple mosquito bites, resulting in movement restriction and pain. Some reactions were observed on international staff who had no previous exposure to mosquito bites while others were observed on individuals with previous mosquito exposure. Some reactions that cause breaks in skin continuity are of concern due to increased risk of complications such as cellulitis and, in rare cases, systemic infection and sepsis. 

Conclusions
As natural disasters become increasingly common with climate change, preventative measures should be taken in areas experiencing lake and river flooding to avoid mosquito hypersensitivity reactions. Best practices include using permethrin on clothing and applying products with 20-50% DEET concentrations every 6 hours to exposed skin. Children and pregnant women can use Picaridin and IR3535 as safe alternatives to DEET. In cases where hypersensitive reactions did occur, treatment was initiated with diphenhydramine cream and bandages to prevent skin breakdown or infection from itching. We also used 0.1% hydrocortisone cream and wrapped extremities to prevent swelling.

“Skeeter Syndrome” and other mosquito hypersensitivity reactions at a sleepaway summer camp in flooded Rainy River Basin

It is estimated that there are more than 250 million Hepatitis B virus (HBV) carriers in the world, causing approximately 600,000 deaths annually from complications. Hepatitis B vaccines are highly effective. Hepatitis B surface antigen (HBsAg) is a marker of current infection, which can be either acute or chronic. We describe a rare case of HBsAg positivity in a patient who was immunized for the first time with the HBV vaccination (Recombivax) 15 days earlier, with all other HBV serological markers being negative, but with markedly elevated initial liver enzymes , which ultimately was related to ischemic hepatitis. It was thought initially that HBV antigenemia post vaccination was short lived. In the literature, the longest case described with transient positive HBsAg in patients for up to 52 days after HBV vaccination. It can be hypothesized that HBsAg positivity post vaccination could be due to regular screening, ESRD patients receiving vaccine boosters, immunization with double dose of vaccine and diminished ability to make HbsAb for neutralization/clearance of inoculate HBsAg. Our case underscores the importance of being aware of vaccination status in patients whom HBsAg comes back positive with negative rest of the serology. This will help avoid the high cost involved in assessing these healthy adults for hepatitis B infection with unnecessary testing. This case highlights that vaccine induced HBsAg reactivity remains a problem, therefore other causes of liver injury must be sought if they present with elevated liver enzymes.

A Rare case of Positive Hepatitis B surface antigen post HBV Vaccination in a Hemodialysis Patient with Elevated Liver Enzymes

Abstract Title: 
An unfortunate case of post-tonsillectomy empyema in a 19-year-old female
Background:
Tonsillectomy is considered a safe and routine procedure with minimal hospital morbidity. According to a retrospective study, in adults, the incidence of 30-day post-operative complication was just 1.2% with the most common complication being infection(58%) of which 1/3 could be attributed to pneumonia. 
Case Presentation:
A 19-year-old female with a history of bilateral tonsillectomy 3 days ago presented with two days of fevers, cough, shortness of breath and pleuritic chest pains. On presentation she was febrile(40.8C), tachycardic(125/min), tachypneic(28/mins) and saturating 87% on highflow-nasal-canula delivery of 40L-100% FiO2. Examination was significant for rales in the right-middle and lower lung fields. White blood cell count on presentation was 19.6K/µL with 81% neutrophils. A CT-chest showed consolidation in the right-lower lobe with ground-glass opacities and nodularity in the right-upper and middle lobes. 
The patient was intubated and transferred to the ICU where she was managed for acute hypoxic respiratory failure with sepsis secondary to pneumonia. She was started on azithromycin and cefepime and a bronchoscopy performed showed purulent matter in the right-lung fields. A repeat CT scan of the lungs 2 days later showed multifocal-pneumonia in the right lung with ipsilateral loculated pleural effusion. A chest-pigtail catheter was placed and the pleural fluid analysis showed an exudative pattern with growth of Streptococcus and gram-positive rods. The patient underwent three sessions of lytic therapy with TPA/dornase but repeat CT scan still showed poor lung expansion and persistent empyema. A video-assisted thoracoscopic surgery was performed which showed fibro-purulent empyema with pus pockets and a lung abscess. Three chest tubes were placed and cultures remained persistently positive. Antibiotics were continued and the chest tubes remained in place until the patient eventually became afebrile. She was later transitioned to oral antibiotics and discharged after gradual removal of the chest tubes. 
Discussion 
This is a great yet unfortunate example of how any medical intervention, no matter how common may lead to serious adverse outcomes. Even though literature highlights pneumonia as a complication of tonsillectomy, but the mind doesn’t immediately jump to the sequelae of pneumonia. Care must be taken when counseling patients regarding the risks of any treatment offered. 


An Unfortunate case of Post-tonsillectomy Empyema in a 19-year-old female

ABSTRACT
INTRODUCTION:
Mucormycosis (Zygomycosis) is a rare opportunistic fungal infection among the immunocompromised hosts caused by fungi belonging to the Mucoraceae family. Increasing case reports of rhino orbital mucormycosis in people with coronavirus disease have been identified, especially from India. About 80% of patients reported having diabetes. There is very limited literature available on COVID-19-associated mucormycosis in renal dialysis patients. We present a case of COVID-19-associated mucormycosis in a non-diabetic 54-year-old Indian male with end-stage renal disease on maintenance hemodialysis treated with steroids during COVID.

CASE REPORT:
A 54-year-old non-diabetic Indian male with End-stage renal disease, on maintenance hemodialysis, presented with left-sided facial pain and swelling, decreased touch sensation over the left face, complete visual loss in the left eye along with proptosis, and complete ptosis of the left eye [Fig 1]. The symptoms started after 4 days of him testing positive for SARS-CoV-2 through the RT-PCR test. He was treated with intravenous dexamethasone 8 mg daily for 8 days and was discharged after being tested negative by RT-PCR and immediately readmitted for current complaints. During the clinical examination of the left eye, the findings of the non-reactive pupil to light, absent extraocular movements, and no perception of light was found, including proptosis. The investigations done are in the following table[table 1,2]. MRI and MRA of the brain demonstrated orbital cellulitis complicated by cavernous sinus thrombosis, superior ophthalmic vein thrombosis, and left medial orbital frontal branch territory/focal cerebritis[Fig 2,3]. Acute infarct was also demonstrated in left pons, left middle cerebellar peduncle, left maxillary and sphenoid sinuses. The radiological findings were consistent with angioinvasive fungal sinusitis. He has been treated with AMPHOTERICIN B 50 mg daily. After 15 days of anti-fungal therapy, he experienced significant relief in left-sided facial pain and swelling. Later, the patient declined the biopsy and was discharged against medical advice. Even though there is a lack of confirmation with biopsy, the relief of symptoms after amphotericin B and the findings of MRI and MRA strongly suggest mucormycosis.

INVESTIGATIONS:
HBA1C: 5.1%
Serum Creatinine: 13.87 mg/dL
Serum Urea : 209 mg/dL
ESR: 100mm/1st hr

CONCLUSION:
Managing the dosage and frequency of corticosteroid intake, should be considered while treating COVID patients, irrespective of their diabetic status. Long-term immunosuppression with glucocorticoid treatment (as in the setting of COVID-19 co-infection) and a history of diabetes, chronic kidney disease, and immunosuppressive therapy increases a patient’s susceptibility to mucormycosis. As mucormycosis can cause significant morbidity and mortality, further study into its severity in previous COVID-19 patients can help develop a histopathological and severity score that incorporates the degree of necrosis, tissue inflammation, fungal load, and angioinvasion to correlate patient outcomes and can be utilized clinically to anticipate the course of the disease. A high index of suspicion and aggressive management is required to improve outcomes

Keywords: COVID-19, Mucormycosis




COVID-19 Associated Mucormycosis in a Non-diabetic CKD Patient: a Case Report

Abstract Title:
Erythema nodosum as key manifestation of histoplasmosis case 

Background:
Histoplasmosis is a common pulmonary disease of fungal origin. However, many cases are asymptomatic. Even when symptoms persist, they are often nonspecific, such as myalgia, arthralgia, fever, and cough.
Erythema nodosum is a common type of panniculitis and is characterized by painful, erythematous subcutaneous nodules, often on the lower extremities. Erythema nodosum is a rare manifestation of histoplasmosis and only occurs in approximately 6% of cases.

Case Presentation:
A woman in her 50s with a medical history significant for hypothyroidism secondary to Hashimoto’s and fibromyalgia presented for an evaluation of painful nodules on her legs and knees that developed over the past week. The bumps started off as bright red and slowly became more bruise-like. She complained her fibromyalgia symptoms had been worse in recent weeks with an increase in myalgia and lethargy.
Due to the variety of stimuli that can trigger erythema nodosum, differential workup was broad, including autoimmune, infectious, and medication reaction causes. Chest x-ray revealed an 8mm nodule in the left hilum with a halo-sign, prompting serum histoplasmosis testing. Diagnosis of histoplasmosis was confirmed by positive titers. The patient later discovered a dead bird in the ceiling above her desk when rewiring work was being done. She was educated that bird droppings are a common vector for histoplasmosis.

Discussion:
A study published in JAMA in 1981 found that 4% of histoplasmosis patients were initially seen with erythema nodosum (11 of 431 cases), where 9 of the 11 patients were female. However, a literature search for erythema nodosum in histoplasmosis cases reveals a gap in relevant research in the last ten years. Larger studies that investigate the relationship between this fungal infection and this inflammatory skin condition are largely outdated. These studies do, however, note the rare but strong association of erythema nodosum with histoplasmosis infections - overwhelmingly with female patients. As a result, case presentations such as the one discussed serve as an important reminder to include fungal infections as a differential diagnosis in the workup of erythema nodosum, especially if the patient is female.

Erythema Nodosum as Key Manifestation of Histoplasmosis Case

Background
Guillain-Barre Syndrome (GBS) is a post-infectious syndrome that involves demyelination of peripheral nerves, classically resulting in an ascending paralysis . Many infectious pathogens have been associated with developing GBS, however the exact cause is still unknown. Over the course of the pandemic, several cases of GBS have been reported concurrently or following infection with COVID-19 . Here, we describe a case of a 40-year-old male who presented with GBS following COVID-19 infection. This case emphasizes how further exploration is necessary to understand the mechanisms of a rare but growing complication of COVID-19 infection and possible preventable measures.

Case Presentation
A 40-year-old male with history of COVID-19 infection one month prior presented with progressive weakness initially in his arms bilaterally that progressed distally to bilateral calves. Neurologic exam was remarkable for reflexes 2+, negative Babinski, and no spasticity. Patient required straight catheterization for inability to void. Initially, the neurology team believed the patient was presenting with a functional neurological disorder, and it was felt atypical for Guillain-Barre given the presence of reflexes and progression of weakness. Initial lumbar puncture showed normal protein levels, no cells, and an elevated opening pressure of 30 cm CSF. A meningitis panel was negative. Patient had worsening dyspnea and respiratory distress, so he was transferred to the ICU and was intubated for decreasing respiratory functioning. Repeat lumbar puncture was done and showed increase in protein with albuminocytologic dissociation, which increased suspicion for Guillain-Barre Syndrome. He was started on IVIg without improvement and was later started on plasmapheresis with subsequent improvement.

Discussion
GBS is an inflammatory polyradiculopathy that has been associated with a multitude of infections, most commonly Campylobacter jejuni. Since the COVID-19 pandemic, there have been several cases of GBS in relation to COVID-19 infection though the prevalence remains unclear. A retrospective review of 45 patients from 29 different studies found increased incidence in those who were male and older in age. Furthermore, over a third of the patients with GBS secondary to COVID required mechanical ventilation, which is elevated compared to those with non-COVID-19 GBS cases. Further research is needed to fully understand this complication of COVID-19 .


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Preliminary Reproducibility Analysis of Diffusion Tensor Imaging of the Achilles Tendon

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