Case Presentation
Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/31269
Browse
Browsing Case Presentation by Issue Date
Now showing 1 - 20 of 31
- Results Per Page
- Sort Options
Item OMT IN THE MANAGEMENT OF CERVICAL RADICULOPATHY IN A PATIENT WITH CERVICAL SPONDYLOSIS(2013-04-12) Long, AliaPurpose: The purpose of this study is to present a unique case of a patient with cervical spondylosis and cervical fusion in whom osteopathic manipulative treatment was used in the management of the patient. Methods: The authors report the case of a 46-year-old man with cervical radiculopathy who received 6 trigger point steroid injections, in addition to a 20-minute session of osteopathic manipulative treatment that focused primarily on the cervical, upper thoracic spine and rib somatic dysfunctions. After treatment, the patient reported immediate improvement of symptoms. Results: A case of cervical radiculopathy in a patient with a past medical history of cervical spondylosis and cervical fusion was presented. The combination of OMT and trigger point steroid injections resulted in improvement of the patient's level of pain, cervical radiculopathy, and nausea. The treatment modalities, possible adverse sequelae as a result of manipulative treatment, review of literature, and discussion of cervical radiculopathy and management of cervical spondylosis are reviewed. Conclusions: Cervical radiculopathy is a common clinical entity that can be frustrating for patients and physicians as a result on the lack of effective treatment options. Because evidence has shown that cervical radiculopathy can be the result of a pathological process or may result from a somatic dysfunction of the spine or ribs, OMT may be an effective treatment modality - alone or combined with other methods.Item MITOCHONDRIAL ENCEPHALOMYOPATHY, LACTIC ACIDOSIS, AND STROKE-LIKE SYNDROME: A CASE REPORT(2013-04-12) Quackenbush, DavidPurpose: Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS), is a rare syndrome inherited through mitochondrial DNA, and thus from the female parent. This case study serves to educate health professionals in the diagnosis, care, and prognosis of individuals with MELAS syndrome. Methods: Information for this case report was collected retrospectively from electronic medical records of the patient's clinical encounters at a family medicine clinic. This information was compared to other case reports and research done on MELAS syndrome and compiled for a poster presentation. Results: MELAS syndrome is a multisystem illness, and individuals often have varied presentations. MELAS syndrome is often found during childhood, and there are several key symptoms that should raise a clinician's suspicion. The patient presented in the case report had many of the health issues associated with MELAS syndrome including seizures and a stroke at a young age. Conclusions: This case report demonstrates the effect MELAS syndrome has on an individual. The case serves to educate health professionals in the common presentation of this rare mitochondrial disease and discusses different treatment modalities that have been attempted among other affected individuals.Item CASE STUDY: ORTHOPEDIC SURGERY IN A PATIENT WITH ACQUIRED VON WILLEBRAND DISEASE(2013-04-12) Alikhan, MirPurpose: To highlight the prevalence of acquired von Willebrand Disease. To review von Willebrand Disease and its treatment prior to surgery. Methods: Collected all the information through electronic records, patients history and pre/post surgery notes. Results: Patients with vWD have a problem with coagulation during major injuries and require Desmopressin among other therapies prior to elective surgeries. Conclusions: Through patient's treatment and literature search, vWD prevalence and treatment was learned. Various types of vWD and its etiologies will be discussed in the poster.Item ANATOMICAL VARIATION OF THE STERNOCLEIDOMASTOID MUSCLE; A CASE REPORT(2013-04-12) Vice, LaurenPurpose: The sternocleidomastoid (SCM) muscle is a prominent neck muscle. It is the main flexor muscle of the neck and an accessory muscle during deep inspiration. Variations of the SCM have been widely recognized and described in medical literature. Supernumerary clavicular origins separating into individual bellies are a defined variant. However, the existence of a thyrohyoid insertion has not previously been described. Methods: Medical students performed a routine cadaver dissection in the University of North Texas Health Science Center's Gross Anatomy Lab. Results: A sternocleidomastoid muscle with four heads was identified on the left side of a 59 year old male cadaver whose cause of death is liver cancer. A typical SCM has origins on the sternal head and clavicular head, and an insertion on the mastoid process. This male cadaver however has two distinct abnormal findings. The SCM shows three clavicular origins separating into individual bellies. Additionally a unilateral thyrohyoid insertion is present, originating from the distal end of the sterno-mastoid belly. While the supernumerary SCM bellies can be explained by abnormal mesodermal splitting, the thyrohyoid insertion presents as a genetic abnormality not previously reported. Conclusions: Surgical awareness of abnormalities is significant, especially in regards to the existence of supernumerary posterior triangles and the additional thyrohyoid head. Furthermore, the clinical implications suggest possible tension headaches, torticollis and even infringement on the thyroid cartilage during swallowing and speech.Item PHELAN MCDERMID SYNDROME: A POTENTIAL UNDERLYING CAUSE OF UNEXPLAINED MENTAL RETARDATION IN THE PEDIATRIC POPULATION(2013-04-12) Pickard, BrennaPurpose: This case report will present information on a rare chromosome 22q13.3 deletion syndrome named Phelan McDermid syndrome(PMDS). With approximately 600 reported cases worldwide and minimal research published,physicians know little about this disorder.The diagnosis of PMDS is rarely diagnosed due to the broad array of presenting characteristics such as neonatal hypotonia, severely delayed speech,dysmorphic features,and global developmental delays.Because the subtelomeric fluorescence-in-situ hybridization(FISH)analysis used to detect the microdeletion is fairly new and the 22q13.3 deletion can go undetected on routine cytogenetic analyses,physicians remain uncertain on how to correctly diagnose these patients.This case report aims to educate others on the phenotypic and behavioral characteristics,genetic testing,and treatment for PMDS,as well as explain the importance of a gene involved named SHANK3.The loss of this gene produces the neurological aspects seen in PMDS,so this report will discuss how this syndrome could be a major underlying cause of unexplained mental retardation(MR)in the pediatric population. Methods: One representative case will be reviewed in detail with the approval of the patient's mother and pediatrician.We will review published literature to describe the clinical features of this syndrome and discuss genetic testing used for diagnosis. Results: Upon reviewing the patient's records,we identified features and comorbidities consistent with the reviewed literature. Due to the 22q13.3 deletion in PMDS,a gene named SHANK3 is lost.Shank proteins play a role in forming nerve connections and are crucial in brain cell communication;therefore,deletions of these genes cause a majority of the symptoms seen.Literature states SHANK3 mutations are found in other disorders which raise the possibility that PMDS is related to other diseases seen today such as schizophrenia and autism. Conclusions: PMDS is an infrequently recognized disorder that has not been extensively studied. Because of the difficulties in detecting this disorder, 22q13.3 deletions may go unnoticed, leading instead to the diagnosis of other MR spectrum disorders. With the presented information, physicians may gain a better understanding of how SHANK3 deletions link PMDS to other disorders and cause it to be a possible cause of unexplained MR.This case report also aims to raise awareness of this disorder so earlier detection may be possible and genetic counseling may be enhanced and utilized more frequently.Item BEHCET'S DISEASE MANAGED WITH ANTI-FUNGAL(2013-04-12) White, JustinPurpose: The purpose of this case presentation is to highlight the effectiveness of Diflucan medication in the treatment of Behcet's disease; specifically noting the benefit as a adjunct to typical corticosteroids. This will promote future studies into the additional properties and uses of anti-fungal medications. It will also provide another "off label" management option for Behcet's disease. Methods: This was a retrospective chart review of a single case. The materials used included progress notes from primary physicians and consults, lab work, and radiology readings. Results: This patient showed significant symptomatic relief while taking anti-fungal or classic corticosteroid treatments. However, the best subjective relief was following segments of dual treatment with Diflucan and corticosteroids. Further research into Diflucan's properties suggested a inhibition of P-450 liver enzyme thus increasing systemic corticosteroid levels. Conclusions: After studying Diflucan's pharmacological properties and effects on P-450, combined with this particular case presentation, we conclude that Diflucan has potential to be an excellent adjunct medication to use with corticosteroids specifically for Behcet's disease. We also concluded that further research could be done into systemic anti-fungal medication as a adjunct therapy with steroids for any autoimmune disease.Item GENERALIZED LYMPHADENOPATHY IN A PATIENT WITH DIFFUSE BILATERAL PULMONARY FIBROSIS(2013-04-12) Melo, LuanaPurpose: To present an unique and atypical case of sarcoidosis and lessons learned from it. Methods: Medical charts, Diagnostic studies, Imaging studies, and Laboratory studies, Consultant notes and referral notes. Results: The patient had 4 lymph noded present throughout his body(left posterior nec, right antecubital fossa, and 2 in the groin) which were nontender, firm, and mobile. He was afebrile and did not have leukocytosis. Chest x-ray revealed diffuse bilateral pattern of micronodular disease with interstitial fibrotic changes within both lungs. CT angiogram revealed diffuse mediastinal, hilar, and upper abdominal retroperitoneal adenopathy. FNA of the lump node in the neck revealed no diagnostic value. HIV status was negative. RPR nonreactive. ANA screen normal. ACE level was elevated. AFP and b-HCG were normal. Echocardiogram revealed an EF of 50-55%. Broncho gram stain, bronchial lavage, and culture were negative. Culture showed no growth at 3 weeks. Fungus smear showed no yeast, no fungal elements seen at 3 weeks. Right Arm Lymph node biopsy showed abudant, back-to-back granulomas with prominent multinucleated giant cells; while the majority of the granulomas are non-caseating, granulomas with central necrosis were not difficult to find. With all the test results back, along with the clinical presentation, physicians were able to diagnose an atypical case of sarcoidosis after ruling out other differential diagonis such as Hodking lymphoma. Conclusions: This case is a great learning experience about expecting the unexpected, and understanding that while most disease processes follow a specific pattern and presentation there will be be cases that are atypical. This case reminds us as clinicians that some cases follow an unusual pattern despite a typical diagnoses.Item USE OF CLOBAZAM AND RUFINAMIDE AS ADJUNCTIVE AGENTS FOR REFRACTORY SEIZURES IN LENNOX-GASTAUT SYNDROME(2013-04-12) Mantilla, EmmanuelPurpose: Lennox-Gastaut syndrome (LGS) is a severe childhood epileptic syndrome characterized by multiple types of intractable seizures, mental retardation, and an interictal slow spike and wave pattern with a slow background on electroencephalogram (EEG). Currently, there are only six FDA-approved drugs for LGS in the US. The purpose of this case study is to determine the efficacy of Clobazam and Rufinamide as adjunctive pharmacologic agents for intractable seizures in patients with LGS, as seen in a 40 year old female recently diagnosed with LGS after being refractory to conventional therapies. Methods: Medical records from a 40 year old patient diagnosed with intractable complex partial seizures dating back to 2000 were studied to follow the progression of treatment and the eventual diagnosis and successful treatment of LGS. Results: The patient, with a long history of daily intractable seizures since infancy, was on four-drug regimen (carbamazepine, valproic acid, zonisamide, and topiramate) and a vagus nerve stimulation (VNS) therapy when she was diagnosed with LGS. Despite her current treatment, she still had numerous atonic seizure attacks daily. After adding two adjunctive medications on her regimen, clobazam and rufinamide, the patient's seizure attacks gradually decreased in frequency and intensity. Currently, patient is seizure-free on a dual pharmacologic therapy of clobazam and rufinamide. Conclusions: The results of this case study suggest that dual pharmacologic therapy of clobazam and rufinamide is effective against refractory seizures in patients with LGS particularly in this patient's case. However, seizures in LGS remain to be a challenge, and further studies are recommended to achieve optimal long-term control of the symptoms of this condition.Item ANTI NEUTROPHIL CYTOPLASMIC ANTIBODY POSITIVE VASCULITIS ASSOCIATED WITH LEVAMISOLE CONTAMINATION IN STREET DRUGS(2013-04-12) White, LeonPurpose: The antihelminth drug, Levamisole is widely used to cut cocaine and has been reported to cause aganulocytosis and neutropenia. It can present with an elvated perinuclear antineutrophil cytoplasmic antibody (P-ANCA), anti-nuclear antibody (ANA), myeloperoxidase (MPO), and proteinase 3 (PR3). The purpose of this communication is to demonstrate potential rheumatological side effect of cocaine use related to levamisole contamination. Methods: We present 2 cases of P-ANCA positive vasculitis in patients with heavy use of cocaine. The pertinent social history, clinical findings and laboratory data were obtained from electronic medical records by authorized physicians. A PubMed search was performed using the terms levamisole and vasculitis, cocaine and levamisole, cocaine and vasculitis, and vasculitis. Articles and cases published within the last 10 years were considered. For the epidemiological statistics, we included data reported by the National Institute on Drug Abuse (NIDA), National Survey on Drug Use and Health (NSDUH), the Center for Disease Control and Prevention (CDC) and United States Drug Enforcement Agency (DEA). Results: Two patients seen in the JPS presented with painful, purpuric skin lesions on their ears, arms, forearms and face. Laboratory assays reveal neutropenia, with a positive ANA and P-ANA. Conclusions: These cases highlight the diagnostic criteria of levamisole induced vasculitis based on the presence of neutropenia, necrotizing vasculitis, rhematological findings, social history, the lack of organ involvement and the location of the lesions. Levamisole vasculitis should be clinically distinguished from other systemic disorders such as Lupus, Wegener's granulomatosis, Churgg-Strauss, and Microscopic polyangiitis.Item BILORRHEA SECONDARY TO BRONCHOBILIARY FISTULA(2013-04-12) Rollins, ChristinePurpose: Bronchobiliary fistula (BBF) is a rare condition with significant morbidity which has been reported to occur most commonly as a complication of hydatid cyst liver disease. This case describes a patient who presented with biliptysis six months following decortication of an empyema which had occurred following partial hepatectomy of a colon cancer metastasis. This is the only case to our knowledge which describes the presentation of a BBF in this context. Its purpose is to highlight an unusual presentation of a condition that occurs most commonly in the United States following surgical repair of trauma to the thoracic cavity. Methods: This presentation provides a detailed explanation of a case that allows the reader to gain knowledge about the various ways in which this particular disease process can present. Results: The patient was diagnosed with BBF and successfully underwent open thoracotomy for fistulectomy and repair. Conclusions: BBF presents a unique and interesting diagnostic challenge, and highlights the importance of a thorough history and physical exam. This condition may arise in a patient with parasitic disease, in patients having undergone previous surgery, or in chronically ill patients with a long history of surgeries, abscesses, or radiofrequency ablation therapy. The prognosis in patients with BBF depends on their ability to tolerate surgery, their overall state of health prior to diagnosis (including their ability to undergo a lobectomy), and recognition of this condition early in its course. Direct open fistulectomy and repair is the most definitive approach to repairing BBF, and with complete drainage and successful repair of the diaphragm provides curative treatment with excellent prognosis for patients with this condition.Item TRICHOSPORON ASAHII DISSEMINATED INFECTION IN A NEUTROPENIC PEDIATRIC PATIENT WITH HIGH-RISK ACUTE LYMPHOBLASTIC LEUKEMIA(2013-04-12) Ryan, KatherinePurpose: The purpose of this study is to report a fatal case of infection caused by Trichosporon asahii in a pediatric patient with acute lymphoblastic leukemia (ALL) and to present an update on systemic trichosporonosis in neutropenic patients with special reference to the treatment and diagnosis of Amphotericin B resistant infections. Methods: A 4-year-old girl was admitted to the hospital with recurrent fevers, bone pain, malaise, and pancytopenia. She was diagnosed with B precursor ALL and a history of asthma and prior corticosteroid treatment. She was started on a an ALL treatment protocol (AALL 1131) as high risk due to prior treatment with steroids. At day 15 of her remission induction therapy, her management was complicated by her left arm suddenly becoming painful and edematous, and she spiked a fever (T-max 40.4° C). Blood cultures Trichosporon yeast species and her absolute neutrophil count (ANC) was 0. She was started on amphotericin B and her CVC was removed. The organism was identified as Trichosporon asahii, a fungal species known for multi-drug resistance. She was then started on voriconazole and continued Amphotericin B and Cefepime for fungal and broad-spectrum bacterial coverage. As her infection persisted, T. asahii was repeatedly demonstrated in blood cultures. Results: In the days following, she developed an oxygen requirement, her abdomen became distended and firm, there was a significant decrease in urine output, and a sonogram showed pyelonephritis. Both lower extremities became edematous and scattered red papules developed on her abdomen, chest, face, and back. She was moved to the PICU 17 days from admission. On day 18, she required intubation and pressor support, G-CSF was started, and the first signs of multi-organ failure were evident. On the 23rd day from her admission, life-supporting measures were discontinued at the request of the family and she died at 1:10am. Post-mortem it was determined that the strain of T. asahii grown from her blood cultures was resistant to amphotericin B and micafungin, but sensitive to voriconazole. Conclusions: With greater awareness of etiologic significance of T. asahii and its drug resistance, future cases of trichosporonosis are more likely to be identified early, based on culture sensitivity, and evaluated for innovative antifungal therapy.Item A CASE OF WEST NILE VIRUS MYOCARDITIS PRESENTING AS NON-ST ELEVATION MYOCARDIAL INFARCTION(2013-04-12) Wardi, MiraiePurpose: This case study will present an atypical presentation of West Nile Virus (WNV) myocarditis in a Hispanic male who presented with palpitations, syncope and chest pain consistent with NSTEMI. Typically, WNV infection is asymptomatic; those who are symptomatic present most commonly with WNV and neuroinvasive disease. Myocarditis is an atypical presentation of West Nile Virus infection. We will illustrate the clinical presentation of WNV myocarditis that initially presented as NSTEMI. Methods: The patient's hospital records, including labs, echocardiography findings and cardiac catherization findings, were reviewed. Results: A 38 year old Hispanic male with a previous history of hypertension, hemorrhagic stroke, hyperlipidemia, sleep apnea, metabolic syndrome and gout presented after falling in his home with a chief complaint of elbow, head, neck and chest pain. The patient reported syncope, palpitations, chest pain but no symptoms associated with seizures. Labs showed elevated troponin of 1.385 and a WBC of 21.4. ECG revealed sinus tachycardia, left axis deviation, left atrial enlargement, left anterior fascicular block and nonspecific ST and T wave abnormalities. The patient was admitted on IV antibiotics and serial troponins were monitored. During the course of the admission, cardiac enzymes progressively trended down. Left heart catherization showed minimum irregularities of the left anterior descending less than 20% without evidence of any obstructive coronary artery disease lesions in any of the coronary arteries. Echocardiogram revealed new heart failure with LV ejection fraction of 35-40% due to global cardiomyopathy. Prior to discharge, the patient was tested for West Nile Virus antibodies and viral antigens. He was sent home on maximum medical therapy for coronary artery disease and CHF. West Nile Virus serology was obtained several days after discharge and revealed that the patient was positive for West Nile Virus infection. Conclusions: This case highlights the need for further investigation of cases presenting with increased troponins and suspicion for NSTEMI. Viral myocarditis should be suspected in symptomatic patients who present during mosquito seasons with new onset and persisting headache with chest pain, increased troponins, significant ECG changes, or new onset CHF. Specifically, West Nile Virus has now been implicated in cases with significant cardiac involvement and should be included in any differential diagnosis concerning the etiology of cardiac events.Item ACUTE DISSEMINATED ENCEPHALOMYELITIS IN A PEDIATRIC PATIENT: A CASE STUDY(2013-04-12) Long, AliaPurpose: The purpose of this study is to present a unique case of a pediatric patient with acute disseminated encephalomyelitis (ADEM) who was treated with corticosteroids. Methods: The pathogenesis of ADEM is primarily unknown. The significance of this case study is to present the clinical findings, neurologic changes during the patient's hospital stay, and describe radiological imaging that ultimately led to the diagnosis of ADEM. Results: A case of ADEM in a patient with a past medical history of mental retardation, ADHD, and Bipolar disease was presented. The combination of high-dose methylprednisolone, occupational therapy, and physical therapy resulted in improvement of the patient's level of pain, neurologic findings, and range of motion in her upper and lower extremities. The treatment modalities, possible long-term adverse sequelae as a result of ADEM, review of literature, and discussion and management of ADEM were reviewed. Conclusions: ADEM is an uncommon phenomenon that can be frustrating for patients and physicians as a result of the difficulty in establishing the diagnosis, unknown etiology, and wide variability in morbidity and neurologic deficits that can result. While evidence has shown that ADEM can be the result of a pathological process or may be associated with vaccinations, high-dose steroids combined with physical therapy and occupational therapy may be an effective treatment modality.Item A RAPIDLY PROGRESSING CASE OF SCHMIDT SYNDROME IN A MALE(2013-04-12) White, JustinPurpose: The purpose of this case presentation is to describe a very unusual presentation of Schmidt Syndrome, a rare multi-organ autoimmune disease. The case is unusual in that the disease rapidly progressed to multi-organ failure and presented in a male; both of these factors are very rare for Schmidt Syndrome. This is an extremely unique case and reporting the clinical management, findings, and symptoms involved in the case will provide supporting evidence/information for future physicians as this disease is a difficult and often missed diagnosis. Additionally, this case may lead to some new insight into disease process and maybe lead to new management strategies or treatments. Methods: The case presentation was a retrospective chart review of a single patient. The materials included progress notes from primary physicians and consults, lab work, and radiology readings. Results: We discuss diagnosis and clinical management of Schmidt syndrome. Management can be particularly challenging as the effected organs have additional effects on each other. Also discussed is a list of other symptoms that may occur in presentation. Conclusions: This is one of the few cases ever reported of a male with Schmidt syndrome. The rapid progression seen in this case has not previously been linked to affected males. However, this case may indicate that while males are effected less often then females, they may have present with a more severe form of the disease and new management techniques should be investigated to better control such a rampant process.Item MELLOW YELLOW: A CASE OF AUTOIMMUNE HEPATITIS IN A 2 YEAR OLD FEMALE(2013-04-12) Singh, AnkitaPurpose: The following case report discusses the significance of promptly diagnosing and managing a child with AIH to prevent irreparable damage to vital organs. Methods: The methods used to evaluate this patient were primarily laboratory studies, which included serial liver enzyme levels, antibodies, abdominal ultrasound, and liver biopsy. Results: On admission, liver enzymes were elevated with AST >1900 u/L and ALT >1400 u/L. Total bilirubin and direct bilirubin were increased at 12.2 mg/dl and 10.2 mg/dl, respectively. These values remained high for one week. Total IgG was elevated to 3200 mg/dl. Antinuclear antibody (ANA) was negative, but antismooth muscle antibody (SMA) and liver-kidney-microsome antibody (anti-LKM) were positive. Ultrasound revealed liver cirrhosis, and liver biopsy was consistent with hepatitis. Conclusions: The results reinforced the diagnosis of Type II AIH. The management for this patient included immunosuppressive therapy and monitoring of pertinent lab values. Since the presentation of AIH in children is variable, the importance of timely diagnosis allows for a child to receive suitable treatment in an efficient manner.Item BEST PRACTICES FOR PANCREATIC MASSES OF UNKNOWN ETIOLOGY(2013-04-12) Bachman, RyanPurpose: A 76 year-old Caucasian male presented with painless jaundice which progressively worsened over one week. The only other complaints the patient stated was an unexplained 10 pound weight loss in the past 2 months and mild fatigue for 1 day. His past medical history was significant for non-small cell lung cancer status post left lower lobe lung resection 8 months ago, hyperlipidemia, COPD, and a past smoking history of 260 pack years. After his lung resection, he had a follow up PET scan that showed a possible nonspecific gallbladder lesion which had never been fully worked up. Methods: Evaluation of the patients mass was performed with an ultrasound of the abdomen that showed a dilated common bile and intra hepatic duct dilation with no stones. A subsequent CT of his abdomen showed a 4cm pancreatic mass with a 1.1cm pancreatic duct dilation. ERCP was attempted for brushings of cells and a stent placement was attempted but was unsuccessful for both. Further workup of his mass with an endoscopic ultrasound and biopsy of the pancreas revealed adenocarcinoma. Results: The differential diagnosis for this patients jaundice was choledocholithiasis versus pancreatic mass that was possibly a metastatic spread from his primary lung cancer several months prior. The ultrasound revealed no stones, which helped rule out the choledocholithiasis. However, the ERCP was attempted and unsuccessful which led to a delay in his definitive diagnosis, as well as the inability to place a stent to relieve his original complaint of jaundice. Conclusions: The evaluation of a patient when pancreatic cancer is suspected should start with a CT scan with IV contrast. This method has a high level of sensitivity for mass and allows for assessment for possible surgical resection of the mass. This patient's PET scan was never worked up by his original physician, which may have led to a delay of his diagnosis which could potentially lead to a less favorable outcome. There is currently no recommended screening method for pancreatic cancer. This leads to only 20% of pancreatic cancers diagnosed when they are localized and potentially cured by surgical resection. Once pancreatic cancer has advanced locally and invaded local vasculature or metastasized it is no longer curative with surgery and there are no set guidelines for treatment.Item RENAL CELL CARCINOMA WITH INVASION INTO THE RENAL VEIN(2013-04-12) Tollemache, JuliePurpose: The purpose of this case presentation is to provide an example of a complex scenario involving renal cell carcinoma invasion into the renal vein. By reviewing research and guidelines surrounding diagnosis, staging and treatment of renal cell carcinoma, the probable outcomes of this case can be addressed. Methods: Medical records were reviewed in order to detail the history, physical exam, surgical intervention, pathology, histology, and staging for a patient with renal cell carcinoma. Results: A 60 year old male presented to urology for follow-up from a recent trip to the emergency department where he was evaluated for gross hematuria and urinary retention. The patient's past medical history was significant for hypertension and diabetes mellitus, type II. Family history was significant only for diabetes. One month later, the patient again presented to urology for follow-up from another visit to the emergency department where he was evaluated for the presence of blood clots in his urine, pain with urination, and chills. An abdominal CT scan revealed a 14 cm renal mass with invasion into the left renal vein to the area over the aorta. An MRI was ordered and an open radical nephrectomy was scheduled.The resected left renal mass was sent to pathology. The overall specimen dimensions were reported as 23.0 x 13.5 x 9.0 cm. Bisection of the kidney revealed a tumor mass with a variegated red-orange cut surface measuring 13.0 x 9.0 x 9.0 cm. Microscopic analysis of the tumor reveals a clear cell carcinoma with gross and microscopic invasion of the renal vein. Conclusions: Diagnosis of renal cell carcinoma is presumptively made based on radiologic imaging of a solid renal mass. Surgical resection tends to be the preferred method since this approach is both diagnostic and therapeutic. Since the 1960s, radical nephrectomy has been the procedure of choice when a study demonstrated a 5-year survival rate increase to 66% from 48% with simple nephrectomy.In the case presented, radiologic imaging revealed a single 13 cm tumor with renal vein invasion, but without lymph node involvement preoperatively classifying it as Stage III. Due to the stage and size of the tumor, absence of evidence of metastatic disease, and stable health of the patient, radical nephrectomy was chosen as the treatment modality.In the case presented, both the high stage and especially the presence of venous invasion are poor prognostic indicators. However, the apparent lack of nodal involvement is favorable.Item THE PRESENTATION OF ALL IN A CHILD WITH DOWN SYNDROME: A CASE PRESENTATION(2013-04-12) Perez, RafaelPurpose: Through case presentation, we emphasize the need to consider the possibility of leukemia when a child presents with severe bone and joint pain. We describe the case of a 4-year-old child with Down syndrome diagnosed with acute lymphoblastic leukemia (ALL), whose main presenting symptoms were bone/joint pain and fever of 5 weeks duration. She was initially diagnosed with osteomyelitis of her left clavicle, which was found to be benign after incision and drainage and surgical biopsy. After an adverse reaction to her antibiotics, she was diagnosed with serum sickness and was given a 5 day course of prednisolone after a fairly benign workup. After referral to a rheumatology clinic with complaints of persistent bone and joint pain, she was finally diagnosed with ALL after finding an elevated LDH and leukemia blast cells appearing on blood smear. Methods: We describe a patient case presentation, including chief complaints, physical exam, lab results/procedures, and diagnosis. In addition, we review research describing ALL presenting primarily with musculoskeletal symptoms, and the characteristics of acute leukemia in patients with Down syndrome Results: In a study of 296 patients reviewed over a 13 year period, it was found that 18% of patients with ALL presented primarily with bone pain. Many had near normal lab values which ultimately delayed their diagnosis of ALL by 2 weeks on average. It is well documented that children with Down syndrome have a 10-20 fold increased risk of ALL when compared to non-Down syndrome children. In this population, ALL is associated with an increased morbidity and mortality. Conclusions: Patients with ALL may present with bone and joint pain and often experience delays in diagnosis. Children with Down syndrome are at higher risk of developing ALL, and this possibility must always be considered in the presence of an otherwise unexplained illness.Item ACUTE GLOBAL AMNESIA WITH HYPERDENSITIES OF BILATERAL TEMPORAL LOBES(2013-04-12) Truong, MelaniePurpose: Case presentation of a 31 year old female with a past medical history of diabetes, hyperlipidemia, and vitiligo who presented with an acute global amnesia and hyper-densities of bilateral temporal lobes. A unique case and the lessons learned. Methods: Medical charts, Diagnostic studies, Imaging studies, Lumbar puncture and Laboratory studies, Consultant notes and referral notes. Results: This case is a journey into the process of elimination as well as trial and error. From laboratory draws for blood; looking for serology, immunologic markers, and complete blood differentials; to imaging studies showing minor arcuate infarcts on CT, and ominous hyper-densities in both temporal lobes of the brain by MRI; we speculate as to the cause. This journey was one of expectant surprise. Acyclovir was prophylactically used to circumvent a herpetic encephalitis. Soon it was found to be unnecessary as the lumbar puncture showed herpes to be an unlikely source. As the days progressed, it became evident that our advanced diagnostic abilities were not satisfactory. The patient did not get better. In the end, after performing lumbar punctures, additional imaging of the blood vessels, and continued laboratory draws in search of an answer; our patient grew weary. A decision to recommend a brain biopsy was presented much too late. The patient decisively declined. Conclusions: As physicians, we want to get to the bottom of any medical problem. Physicians are often prompted to find the answers to patients' problems everyday. In medical texts and in pathology books, it seems so convenient. A case is presented, a trail of diagnostic study often points to the ultimate answer; the case is complete and the book can be closed. Unfortunately, in real life, people live with unsolved issues all the time. So our patient, after over a week in a confined space, decided that she no longer cares enough to find the diagnosis. She knows she cannot remember some things and that it worries her family, but she had had enough. The lesson learned here is that regardless of how severe or esoteric the problem; an expedient management of the case may have been better served. For instance, recognizing the need for a brain biopsy earlier rather than later may have elucidated a possible diagnosis. Second, it isn't the final diagnosis that matters to a patient, but the freedom to explore it if she so chooses to&or not.Item PROPRANOLOL FOR MANAGEMENT OF INFANTILE HEMANGIOMAS(2013-04-12) Nguyen, DianaPurpose: Infantile hemangiomas (IHs) are the most common developmental vascular abnormalities of childhood. These benign lesions undergo a rapid growth phase during the first few months, followed by spontaneous involution, in most cases, without any major subsequent complications. However, a minority of IHs can cause significant functional impairment or disfigurement, indicating the need for therapy. Systemic corticosteroids were initially considered the first-line treatment. Recently, propranolol was incidentally discovered to demonstrate increased efficacy in promoting the reduction of hemangiomas, in addition to fewer side effects compared to steroids. This case report documents the effects of propranolol therapy on the management of a patient with an extensive right-sided facial hemangioma affecting the periorbital and nasal regions. Methods: Patient was 3 months of age when first seen for consultation for a large right-sided facial hemangioma. He was managed with an oral suspension of Propranolol 20mg/5 ml. On the first two days of treatment, the patient was given one daily dose of .5mg/kg, and on days 3-7, he was given .5mg/kg twice a day. At one week, the dose was increased to 1 mg/kg twice a day. A follow up was conducted at two weeks, then once every month. The response to propranolol therapy was documented using clinical observation and photographs. Results: Clinical improvement of the IH was noted 10 days after initiating propranolol therapy. Over a 5 month course of treatment, the lesion softened and flattened in appearance, as well as changed in color from red to deep purple to a more soft purple with flesh toned areas. An impressive regression in size of the lesion was noted, enabling patient to open and close the right eye without difficulty. Conclusions: Propranolol therapy has been documented for it's efficacy and safety in the management of IHs that pose a high risk for disfiguring complications. This case report confirms the results of previous studies. The patient's hemangioma demonstrated drastic improvement in response to propranolol therapy in terms of both appearance, as well as reduction in size of the lesion, contributing to an improved quality of life.