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AMA Research Challenge 2022

The risk of assumptions when approaching abdominal pain

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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


poster

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 .


Guillain-Barre Syndrome Secondary to COVID-19 Infection: A Case Report

Introduction:
Creutzfeldt-Jakob disease is a spontaneous neurodegenerative disease secondary to the accumulation of misfolded prion proteins depositing in neurons. Clinical findings include rapidly progressive dementia, myoclonus, sharp waves on EEG, and an akinetic mutism state. Creutzfeldt-Jakob disease is often mistaken for progressive multifocal leukoencephalopathy as the afflictions share many of the same symptoms; however, given the extremely high mortality rate of Creutzfeldt-Jakob disease, an accurate and early diagnosis is imperative. This is a case report of a patient misdiagnosed with progressive multifocal leukoencephalopathy and later found to have sporadic Creutzfeldt-Jakob disease via diagnosis after MRI.
Case Presentation:
A 62-year-old male with no significant past medical history presented for evaluation of rapidly progressive dementia and decreased oral intake. Four months prior at baseline, the patient was healthy and athletic but began experiencing dizziness and increasing falls. Imaging done two months prior to admission indicated Creutzfeldt-Jakob disease; however, after multiple examinations, the patient was diagnosed with progressive multifocal leukoencephalopathy via positive Human polyomavirus 2 (JC virus) serum and cerebrospinal fluid PCR tests. During a hospital stay, the progression of the condition led to failure to thrive and urinary and bowel incontinence. Upon resolution of the patient’s acute kidney injury, the patient underwent an MRI of the brain which showed restricted diffusion/cortical ribbon sign in bilateral bifrontal cortical gyri and restricted diffusion in the bilateral basal ganglia and pulvinar. "Hockey-stick sign" with restricted diffusion in the bilateral basal pulvinar and dorsal medial thalamus was also noted. These changes are consistent with the sporadic form of Creutzfeldt-Jakob disease. The patient was discharged home with palliative care.
Conclusion:
This case underlies the importance of rapid diagnosis and differentiation between progressive multifocal leukoencephalopathy and Creutzfeldt-Jakob disease as either has different morbidity and mortality risks. Studies have shown that stratifying the different types of rapidly progressive neurodegenerative conditions is influenced by hesitance to make a diagnosis with no treatment option versus diagnoses with viable treatment options. Biopsy remains the gold standard of diagnosis for JC virus; however, clinical imaging and cerebrospinal fluid PCR are more commonly used for the diagnosis due to their high specificity. These tests have a lower sensitivity, in which case, patients are often definitively diagnosed with biopsy ante or post-mortem. This case was characterized by clinical suspicion for Creutzfeldt-Jakob disease, but lack of access to medical records delayed repeat MRI and allowed the progression of the disease under the diagnosis of JC virus. Of note, there are no reported cases in the literature of false positive cases of JC virus which is representative of the high specificity of the tests.

How to Distinguish Creutzfeldt-Jakob Disease from Progressive Multifocal Leukoencephalopathy when the Cerebrospinal Fluid Fails

Abstract Title: Human intestinal spirochetosis in a patient with AIDS

Background: Although well-documented in veterinary literature, human intestinal spirochetosis (HIS), the infection of spirochetes in colonic mucosa, is less well-understood. The anaerobic spirochetes, namely Brachyspira species, have been identified as causative organisms. HIS is usually identified on colonic biopsy. Its clinical significance often depends on host immune system. Clinical presentation may range from asymptomatic colonization to invasion causing bloody diarrhea and abdominal pain. We present a patient with a discovery of intestinal spirochetosis on screening colonoscopy. 

Case Presentation: A 50-year-old American male with AIDS and undetectable HIV viral load presented for his first screening colonoscopy. He denied any gastrointestinal complaints such as abdominal pain, constipation, diarrhea, bleeding, or any change in bowel habits. He has one bowel movement per day. He is sexually active strictly with men and his last sexual activity was over one year ago. An uncomplicated colonoscopy was performed and revealed three hyperplastic polyps in the rectum and one hyperplastic polyp in ascending colon, which were removed. Histologic examination of the polyp found in the ascending colon revealed mucosal filamentous, densely packed spirochetes and no dysplasia or carcinoma. His CD4+ T-cell count was 190, and RPR and syphilis serologies were non-reactive. Rectal gonorrhea and chlamydia were negative within one year. Because the patient is asymptomatic, no treatment is currently planned. The patient was counseled regarding symptoms that warrant treatment, including bloody stools and changes in bowel habits, with close follow-up for symptom monitoring. 

Discussion: HIS is a rare finding, particularly in more developed countries. This patient was found to have asymptomatic spirochete colonization and elected to forego treatment at this time. However, intestinal spirochetes have the potential to invade and destroy colonic mucosa, causing more severe symptoms, particularly in those who are immunocompromised, such as HIV status. HIS has also been found at higher rates in men who have sex with men, and some reports suggest that it may be sexually transmitted depending on context. Therefore, we encourage practitioners following patients with asymptomatic HIS to have regular follow-ups for symptom monitoring, screen for other sexually transmitted infections, and be ready for treatment with metronidazole if symptomatic.


Human intestinal spirochetosis in a patient with AIDS

Invasive Aspergillosis Presenting as Endophthalmitis in Heart Transplant Recipient

Monkeypox is a re-emerging zoonotic disease of the orthopoxvirus genus presenting with myocutaneous symptoms similar to those caused by smallpox. Patients infected with monkeypox may experience a prodromal period with flu- like symptoms lasting between 1-4 days, an asymptomatic incubation period lasting 7-17 days and a symptomatic rash period lasting 14-28 days between the appearance of widespread vesiculopapular lesions and desquamation. Specific risk factors for the current monkeypox outbreak include HIV infection, prior STI infection, male sex, young-adult age (specifically being in the 20’s-30’s age group), engaging in risky behaviors (such as unprotected sex) and men having sex with other men. We report the case of a 38-year old HIV+ patient testing positive for monkeypox, COVID-19 and herpes who presented to the emergency department with widespread vesiculopapular lesions. One week prior to ED presentation, the patient experienced flu-like symptoms including fever and, two days later, developed a vesiculopapular rash beginning on his face and spreading downwards to his extremities, trunk and genitalia. The flu-like symptoms developed twelve days after attending an event where the patient reported having sex with multiple other men. The patient was treated with intravenous fluids and supportive care alongside his HIV medications. Nine days after initial ED presentation, all skin lesions were desquamated and the patient was discharged from the hospital. To our knowledge, this is one of the first reported cases of co-infection with COVID-19 and monkeypox in Florida and the United States more broadly. Despite our patient’s several risk factors for monkeypox infection, and immunosuppressed status, he experienced an uncomplicated clinical course. As vaccination and antiviral treatments become more available for monkeypox patients, our case suggests supportive care with airborne and contact precautions may be adequate in the treatment of future monkeypox patients where these treatments are unavailable.

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The risk of assumptions when approaching abdominal pain

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

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