Dermatofibromas are benign cutaneous soft-tissue tumors characterized by solitary or multiple, firm red-brown to black dermal nodules found on the trunk or extremities. Dermatofibromas most frequently affect middle-aged adults and have a slight preponderance in females. Variants of dermatofibroma include hemosiderotic, aneurysmal, epithelioid and deep fibrous histiocytomas, cellular, lipidized, lichenoid, keloidal, atrophic, and atypical. 

Diagnosis of the classical type of dermatofibroma is made clinically and based on dermoscopic patterns; however, the clinical and histologic heterogeneity observed in dermatofibroma variants can pose a diagnostic challenge and may be difficult to distinguish from potentially aggressive malignancies. Notably, hemosiderotic dermatofibroma has been reported to clinically simulate melanoma, while atypical dermatofibroma, is often mistaken histologically for sarcoma. 

Herein, we report a unique presentation of a patient with a recurrent atypical melanocytic nevus and multiple benign dermatofibromas masquerading as potentially malignant counterparts.

Dermatological Deception: Massive Dermatofibroma and Atypical Melanocytic Nevus Mimicking Malignancy

A broad differential exists for infectious esophagitis including fungal, viral, and bacterial pathogens. Although often seen in immunocompromised patients, certain risk factors should prompt consideration of unusual etiologies in immunocompetent hosts. This case explores a 24-year-old female with known eosinophilic esophagitis (EoE), initially presenting with odynophagia and globus sensation, found to have HSV esophagitis. It is known that HSV esophagitis predominantly occurs in hosts with impaired immunity resulting from chemotherapy, transplantation, or HIV infection: all risk factors that this patient did not have. This poster presentation explores the pathophysiological relationship between EoE and HSV esophagitis in an otherwise immunocompetent host as well as the role of occupational exposures as risk for primary HSV infection. Our goal is that this case 1) prompts physicians to consider uncommon etiologies for presumed infectious esophagitis to expedite treatment and clinical improvement, and 2) inspires further research into the relationship between EoE and HSV esophagitis as well as the preferred treatment regimen.

A Sticky Situation: Odynophagia and Globus Sensation in an Immunocompetent 24-Year-Old Female

Background
Shigella is a Gram-negative, facultative anaerobic bacteria that causes a gastrointestinal infection characterized by bloody diarrhea. First-line treatment is azithromycin; however, in the men who have sex with men (MSM) population, Shigella is known for higher rates of azithromycin resistance. Other treatments, including trimethoprim-sulfamethoxazole, fluoroquinolones, and ampicillin, are also increasing in resistance. 

Glucose-6-Phosphate Dehydrogenase (G6PD) is an enzyme that prevents cellular damage from reactive oxygen species (ROS), to which red blood cells are especially susceptible. G6PD-deficiency is an inherited disorder characterized by acute hemolytic anemia after exposure to high levels of ROS from foods and certain antibiotics, including many that are used for treatment of Shigella.

Case Presentation
A healthy 28-year-old male with a history of MSM activity presented to the emergency department (ED) with four days of 15-20 daily episodes of increasingly bloody diarrhea and a recent exposure to a sick contact with similar symptoms. As an Active Duty Sailor, he initially sought care from his ship’s physician who prescribed azithromycin and acetaminophen without relief. In the ED, he was tachycardic and physical exam revealed tenderness of left abdominal quadrants with rebound. Rectal exam showed bright red blood and watery brown stool. Lab work was notable for leukocytosis, acute kidney injury (BUN 40, Cr 3.3), and lactate 2.1. A CT abdomen/pelvis revealed moderate proctocolitis. He reported no known drug allergies, and was given fluids, ciprofloxacin 500 mg, and metronidazole 500 mg for presumed infectious diarrhea. He was admitted to the Internal Medicine Ward, where GI Stool PCR resulted positive for Shigella. Chart review indicated a history of G6PD-deficiency, at which point he was transitioned to ceftriaxone from ciprofloxacin with an Infectious Disease consult. He clinically improved and was discharged home on Augmentin; however his symptoms did not resolve on Augmentin. Culture sensitivities resulted after his discharge, which demonstrated resistance to ampicillin. He was switched to cefpodoxime per Infectious Disease recommendation and recovered fully.

Discussion
This case illustrates the value of complete history gathering in determining a patient’s full spectrum of risk factors. Relevant for this patient was his sexual history and medication intolerances that he did not initially disclose. It also highlights the growing importance of alternative treatment regimens to mitigate the adverse effects of increasing global rates of antibiotic resistance, especially for patients with complex histories and medication intolerances.

Diarrheal Dilemma: G6PD-Deficiency Complicating Treatment of Antibiotic- Resistant Shigella in the MSM Population

Background
Most of the available COVID-19 outcome data in Solid Organ Transplant (SOT) recipients does not suggest a higher mortality rate in the SOT population. Though theoretically immunosuppressive medications might be associated with worse outcome, its immunomodulatory effect might be beneficial.

Methods
We retrospectively analyzed the effect of dose-reduction of mycophenolate, tacrolimus, and prednisone on the severity of COVID-19 in SOT recipients diagnosed with COVID-19 at the Center for Transplantation of the University of Kansas Medical Center between January 1, 2020 and December 31, 2022. Severe COVID-19 was defined as development of hypoxia while the patient is on room air during a 21-day period following COVID-19 diagnosis. To evaluate the effect of dose changes after the diagnosis of COVID-19 on the odds of severe COVID-19, we subset our data based on whether patients were taking mycophenolate (n = 449), tacrolimus (n = 537) or prednisone (n = 386) at the time of diagnosis. Within each subgroup, we fit a logistic regression model with severe COVID-19 as the response variable and adjusted for the relevant immunosuppressant and a set of covariates.

Results
In our SOT population, 570 patients were diagnosed with COVID-19 (458 kidney, 73 liver, 54 heart, 43 pancreas, and 8 lung recipients). The median patient age was 54 years, 59% were male, and 70% were white. After adjusting for other covariates, a mycophenolate dose-reduction of < 50% was associated with an odds ratio of 1.89 (95% CI: 0.96-3.70; p=0.06) for developing severe COVID-19. Similarly, decreasing the dose of mycophenolate by  50% was associated with an odds ratio of 2.44 (95% CI: 1.02-5.85, p=0.05) for developing severe disease. Tacrolimus dose reduction did not increase the risk of severe COVID-19. An increase or a decrease of prednisone dose was not associated with severe COVID-19. 

Conclusion
The reduction of mycophenolate dose when a SOT patient is diagnosed with COVID-19 should be discouraged, especially if the patient has mild disease. 


Reducing the dose of Mycophenolate in Solid Organ Transplant Recipients Diagnosed with SARS-CoV-2 Infection Increases the Risk of Severe COVID-19

Lymphomatoid papulosis (LyP) is a chronic cutaneous CD30-positive lymphoproliferative disorder that is characterized by red-to-violaceous crops of papulonodular skin lesions. Although LyP carries a positive prognosis, there is consensus that LyP is associated with a history of or subsequent development of lymphoma. Herein, we present a case of LyP in a patient with a history of cutaneous B-cell lymphoma. The patient is a 67-year-old male with a history of treated cutaneous B-cell lymphoma two years prior to presentation, currently in remission, presenting with a two week history of painful hemorrhagic papules on his hands. Biopsy revealed a dense lymphomatoid infiltrate with admixed histiocytes and dermal hemorrhage. Tumor cells expressed CD3 and CD4, with marked loss of CD7. Small clusters of CD30+ cells were noted. There was no significant expression of CD20, CD56, or myeloperoxidase. At subsequent follow up, his original lesions were healing, but he had developed a new crop of lesions on the foot and both hands. Given the patient’s clinical course and histopathologic findings, a diagnosis of LyP subtype C was favored. The patient’s presentation was notable due to antecedent history of cutaneous B cell lymphoma, in addition to confinement to acral sites.

Lymphomatoid Papulosis Type C in Patient with History of Cutaneous B-Cell Lymphoma

To mount a robust immune response, naïve T cells must differentiate into cytokine producing effector T cells. However, if T cell activation and differentiation is poorly controlled, excess inflammation can occur, resulting in allergy or autoimmune disease. Thus, protective immunity is dependent on a fine tuning of differentiation and cytokine production by T cells. This can be accomplished by E3 Ubiquitin Ligases, as these enzymes regulate the levels of cellular proteins. We performed a screen to identify Cullin E3 ubiquitin ligases that were active in T cells and identified Cullin 5 (Cul 5) as being the most dynamically activated Cullin during T cell activation. While it is known that Cul 5 aids in the formation of the CRL5 complex (for Cullin Ring Ligase), whether and how Cul 5 regulates immune system function is unknown. We have now generated mice that lack Cul 5 in T cells. Initial characterization of these Cul 5 fl/fl CD4-Cre mice revealed that Cul 5 is critical in preventing spontaneous and allergen-induced inflammation in the lungs by inhibiting Th2 differentiation in CD4 T cells. To see if this protective effect of Cullin 5 was important at other mucosal surfaces, we employed a colitis model, known as DSS-induced colitis to experimentally mimic Inflammatory Bowel Disease (IBD). We found that mice that lack Cul5 in T cells showed significantly more weight loss and colon pathology than their wild type counterparts. Surprisingly, the mice did not show increased cytokine production by CD4 T cells, rather, they showed high numbers of CD8+ T cells, that while activated, were less likely to produce IFN-γ. Taken together, our preliminary data support that Cullin 5 may regulate CD8 T cells responses either by limiting cytotoxic activity or by promoting IFN-γ production to facilitate macrophage bactericidal activity. Our data support that Cul 5 prevents colitis by regulating CD8 T cell numbers and/or function.

Cullin 5 Limits Disease Severity in DSS-Colitis

Background: Acinetobacter baumannii is one of the world’s most multi-drug resistant (MDR) pathogens. Traditionally responsible for causing nosocomial pneumonia, bacteremia, and soft tissue infections in critically ill and immunocompromised patients, A. baumannii has evolved to propagate a growing number of atypical infections, including fatal cases of necrotizing fasciitis (NF; i.e., flesh-eating disease), over the past decade. Concerningly, these NF A. baumannii (NFAb) isolates display enhanced virulence and antibiotic resistance uncharacteristic of type strains, resulting in limited efficacy of current therapeutics. As such, understanding of mechanisms by which these strains evade host defenses, environmental stress, and previously effective antibiotics is imperative, yet remains scant. Our lab has obtained two MDR NFAb isolates from a case of NF that led to sepsis and death over 36-hours. The present study sought to elucidate resistance mechanisms of these isolates for the identification of new drug targets to treat MDR A. baumannii infections.

Methods: To determine if NFAb resistance and propagation of infection involves the mechanism of host immune cell entry, NFAb isolates (i.e., NFAb-1 collected pre-mortem from blood and NFAb-2 collected post-mortem from tissue) were co-incubated with human-derived THP-1 macrophages with or without pre-treatment with Cytochalasin D, an inhibitor of phagocytosis. A colistin-protection assay was performed to isolate viable intracellular bacteria, which were quantified by colony forming units (CFUs) after 24 hours. To assess resistance to desiccation, dried NFAb isolates and type strains were resuspended, and surviving cells were quantified by CFUs at 1, 5, and 7 day intervals. Lastly, transformation efficiency was assessed using selective media and fluorescence via flow cytometry, then reported as transformant CFU:total CFU.

Results: Similar to type strains, NFAb isolates were found to primarily enter macrophages via macrophage-mediated phagocytosis; however, both NFAb isolates displayed greater intracellular entry and survival in the host immune cells than type strains. Interestingly, NFAb-1 demonstrated greater resistance to desiccation than NFAb-2 over the course of 7 days. Although previous studies highlighted genomic differences between NFAb-1 and NFAb-2, no differences were observed in transformation efficiency between NFAb isolates and type strains.

Conclusion: Collectively, these results suggest NFAb isolates utilize a variety of resistance strategies to survive, and possess a profound ability to rapidly adapt, even within the context of a single infection. Moving forward, we aim to identify the genes propagating the intracellular survival and infection demonstrated by these isolates to serve as potential targets for novel therapeutics.

Utilizing Atypical Isolates of Acinetobacter baumannii to Uncover Novel Mechanisms of Resistance

Human Immunodeficiency Virus 1 (HIV-1) is a retrovirus that primarily infects human CD4+ T cells, a key cell-type in the adaptive immune system. The virus establishes a latent reservoir in the early phases of infection that persists in people living with HIV-1 (PLWH) despite effective antiretroviral treatment (ART). Designing strategies to target the HIV-1 reservoir is critical to achieve progress towards a cure. In eukaryotic and prokaryotic cells, and in viruses, antisense transcripts have been shown to exist as long, non-coding RNAs (lncRNA) or coding RNAs (mRNA). Some viruses, like Human T-cell Leukemia Virus Type 1, encode antisense genes to regulate viral expression and replication. HIV-1 antisense transcripts (AST) have been detected in in vitro and ex vivo studies and have been shown to induce viral latency through methylation of histone 3 lysine 27 by recruiting the polycomb repressive complex 2 (PRC2). Our previous studies demonstrated the presence of HIV-1 AST in vivo at levels of 1-3 copies in a median of 5% infected peripheral blood mononuclear cells (PBMC), suggesting a potential role in inducing viral latency in vivo. To determine if HIV-1 AST expression affects levels of plasma viremia, we designed an assay to measure AST expression in PLWH with high viral loads (non-controllers, viral load 5,000-200,000 copies/mL), with low viral loads (viremic controllers, 50-2,000 copies/mL), and with undetectable viral loads (elite controllers, <40 copies/mL). The assay is a limited-dilution, digital PCR approach that targets HIV-1 AST in donor blood cells using donor-specific primers. First, nucleic acid is extracted and subjected to thorough DNase treatment. The remaining antisense RNA is reverse transcribed using a primer targeting the AST region. Detection is achieved with a fluorescent probe and reported as the number of HIV-1 AST molecules per 100 infected cells. We measured AST levels using ACH-2 cells (a model of HIV-1 latency) as a positive control with an average of 3.18 copies of AST per 100 infected cells, as expected. Negative controls included no reverse transcriptase and no template to ensure complete DNA digestion and no mis-priming nor contamination. Our preliminary data includes 4 donor samples in which HIV-1 AST was detected at 1-53 per 100 infected cells. Future studies will determine if AST functions to control HIV-1 replication and induce viral latency in vivo.

Investigation of HIV-1 Antisense Expression In Vivo

Background
Coronaviruses, including SARS-CoV-2, cause the respiratory disease known as COVID-19. Some individuals experience persistent symptoms, referred to as long COVID. Among the complications reported after COVID-19 are Guillain-Barre Syndrome (GBS) and its variant, Miller Fisher Syndrome (MFS). MFS causes muscle weakness, ataxia, and ophthalmoplegia. Treatment typically includes intravenous immunoglobulin (IVIG) or plasmapheresis. While most COVID-19-associated MFS cases improve with IVIG, this case highlights a patient who did not show symptomatic relief.
Case Presentation
A 57-year-old male with a medical history of prior COVID-19 infection, facial fracture repair, and treated syphilis presented to the emergency department (ED) with sudden-onset double vision, pain behind the left eye, dizziness, frontal headache, and generalized weakness. The diplopia began five days after the initial COVID-19 diagnosis and progressively worsened. The patient had experienced a dry cough and rhinorrhea prior to admission, with a confirmed SARS-CoV-2 infection. On admission, the patient exhibited facial nerve weakness, impaired eye movement, ptosis, diminished reflexes, and generalized weakness. Sensation, cerebellar function, and gag reflex were normal, but the patient required a cane for ambulation. The patient 
underwent a comprehensive evaluation and was diagnosed with Miller Fisher Syndrome. Treatment with IVIG and prednisone was administered, but there was no improvement in symptoms even after 8 weeks.
Discussion
This case report presents a unique case of a patient who developed MFS following a COVID-19 infection. Despite receiving IVIG treatment, the patient did not experience any improvement in symptoms even after 8 weeks. This is a notable finding as most reported cases of COVID-19-associated MFS have shown some improvement after IVIG therapy within 2 weeks. The patient's prolonged lack of symptomatic improvement raises questions about potential modifications of MFS or resistance to standard treatment. Further research is needed to understand the relationship between COVID-19 and MFS, including potential predisposing factors and pathophysiological mechanisms. The case highlights the need for targeted therapies and diagnostic markers for MFS in the context of COVID-19, as well as the importance of early detection and understanding the impact of different strains of the virus on neurological manifestations.



Title of Persistent Miller Fisher Syndrome Following COVID-19 Infection: A Case Report

Background
Scleroderma is a rare, chronic autoimmune disease that is characterized by thickening of the skin and other connective tissues in the body. Nodular scleroderma (NS) is a rare cutaneous form of scleroderma that can occur primarily with systemic sclerosis. Due to the rarity of NS, it is important to recognize these lesions, if presenting early in disease progression, as a sign of underlying scleroderma before internal organ damage becomes apparent. 

Case Presentation
A 42-year-old female with a history of systemic sclerosis presented with an enlarging left supraclavicular nodule. Upon physical exam, a 1.1cm erythematous nodule was found. The patient had clinical findings consistent with systemic sclerosis, including Raynaud’s phenomenon, gastroesophageal reflux disease, sclerodactyly, dyspnea on exertion, and skin tightening. The patient had been treated with CellCept 1500mg twice daily and responded very well to therapy. Pertinent laboratory data included speckled antinuclear antibodies (1:320 titer) and positive anti-RNA polymerase III antibodies (>80 units). 

The lesion was initially excised to rule out diagnosis of a cyst. However, histopathological analysis demonstrated a nodular proliferation of dense fibrotic collagen with scattered bland fibroblasts. A sparse perivascular and periadnexal lymphocytic infiltrate in the dermis was present with notable eccrine coil trapping. A CD34 stain showed markedly diminished dermal dendritic cells within the fibrotic nodule. Considering the patient’s known history of anti-RNA polymerase III-positive systemic sclerosis and histopathological findings, the focal lesion was consistent with nodular scleroderma. No subsequent treatments were performed.

Discussion
Nodular scleroderma is an atypical cutaneous presentation of systemic sclerosis and patients who are well-controlled on immunosuppressive therapy with few to no signs of internal organ disease are still susceptible to developing these lesions. Thus, diagnosis and treatment of NS remains a challenge. NS usually presents as 2 mm - 3 cm firm nodules or plaques resembling keloid or morphea, usually distributed on the trunk, neck, proximal extremities, and face. The pathogenesis of NS is also not well understood. Previous reports have shown that there may be a role for increased expression of connective tissue growth factor, tenascin, epidermal growth factor, or transforming growth factor beta in the formation of NS. 

Furthermore, treatment of NS is difficult as these lesions are resistant to many non-surgical interventions and remain stable over time. As in our case, surgical excision of NS has been the only treatment reported so far that results in full removal of NS, but not necessarily prevention of NS recurrence.


Systemic Sclerosis with a Rare Presentation of Nodular Scleroderma

**Scoring is only possible in the semifinals hall**

**Abstract:**



Saccharomyces cerevisiae (Baker’s Yeast) Pneumonia in an Immunocompromised Host

Background: Antimicrobial stewardship programs (ASP) are a key component of efforts to combat antimicrobial resistance. These programs are designed to reduce to non-indicated use of antimicrobials, reduce adverse drug reactions, and provide guidance for the indicated uses of antimicrobials. We audited adherence to vancomycin use guidelines to determine if prescribers are compliant with vancomycin use guidelines and calculated the rate of non-indicated vancomycin use through chart review. 
Methods: We reviewed vancomycin prescriptions for four months in 2022 and determined if vancomycin use was indicated according to hospital guidelines. Chart review consisted of evaluating the clinician’s stated reason for starting vancomycin, if that indication was adherent to guidelines, and the duration of antibiotic use. We compared the total number of vancomycin prescriptions during this period to nonindicated prescriptions during this time period. 
Results: The rate of non-indicated vancomycin use was 4.8%. The most common non-indicated use of vancomycin was when there was no identifiable or presumed bacterial infection (36.4% of non-indicated use). The second most common reason was the organism was susceptible to a first line antibiotic (32.7%). The third most common reason was the prescription of vancomycin for community acquired pneumonia (CAP) with low a MRSA risk (29.1%).
Conclusion: 95.2% of vancomycin orders were adherent to hospital policy. Adherence to ASP guidelines reduces vancomycin misuse and promotes antibiotic de-escalation. This reduces the amount of unnecessary vancomycin use within the hospital and protects patients from unnecessary antibiotic exposure. 


Underline digital video library

Dermatological Deception: Massive Dermatofibroma and Atypical Melanocytic Nevus Mimicking Malignancy

A Sticky Situation: Odynophagia and Globus Sensation in an Immunocompetent 24-Year-Old Female

Diarrheal Dilemma: G6PD-Deficiency Complicating Treatment of Antibiotic- Resistant Shigella in the MSM Population

Reducing the dose of Mycophenolate in Solid Organ Transplant Recipients Diagnosed with SARS-CoV-2 Infection Increases the Risk of Severe COVID-19

Lymphomatoid Papulosis Type C in Patient with History of Cutaneous B-Cell Lymphoma

Cullin 5 Limits Disease Severity in DSS-Colitis

Utilizing Atypical Isolates of Acinetobacter baumannii to Uncover Novel Mechanisms of Resistance

Investigation of HIV-1 Antisense Expression In Vivo

Title of Persistent Miller Fisher Syndrome Following COVID-19 Infection: A Case Report

Systemic Sclerosis with a Rare Presentation of Nodular Scleroderma

Saccharomyces cerevisiae (Baker’s Yeast) Pneumonia in an Immunocompromised Host

Are Vancomycin Use Guidelines Followed in a Community Hospital? Examining Vancomycin Prescriptions Through Retrospective Chart Review

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