Case Presentation
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Item A CASE OF HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY WITH NO PREVIOUS CARDIAC HISTORY(2013-04-12) Wardi, MiraiePurpose: This case study will depict the presentation, diagnosis, management and prognosis of hypertrophic obstructive cardiomyopathy (HOCM) in a 64-year-old Caucasian female with no previous cardiac history who presented with dyspnea and an incidental systolic murmur. HOCM is a genetic disease caused by mutations of sarcomere genes that encode components of the contractile apparatus of the heart. We will illustrate an atypical presentation of HOCM in a female with no previous cardiac history and discuss appropriate diagnostic and treatment options. Methods: The patient's medical records, echocardiography reports, and cardiac cauterization reports, were reviewed. Results: A 64-year-old female with a past medical history of hyperlipidemia, tobacco dependence and COPD presented to her pulmonologist with worsening dyspnea on exertion. Upon physical examination, a global III/VI systolic ejection murmur that increased upon standing was heard. Upon evaluation by cardiology and review of echocardiography results, it was found that the patient has severe HOCM with an outflow gradient of 144 mmHg with peak velocities across the left ventricular outflow tract (LVOT) at 8.1 cm/s. There was also severe global left ventricular hypertrophy and asymmetric septal hypertrophy. Left ventricular ejection fraction was preserved at 55%. Systolic anterior motion causing severe mitral regurgitation in an eccentric anterior direction with thickened mitral leaflets was also found. Cardiac catherization revealed mild nonbstructive coronary artery disease, moderate or severe pulmonary hypertension and severe left ventricular to aortic pressure gradient. Holter monitoring revealed sinus rhythm, no NSVT and no significant pauses. The patient was counseled on treatment options which include either myomectomy or alcohol septal ablation. Conclusions: A leading cause of sudden cardiac death in young athletes, HOCM can also present as a sporadic form in older individuals. When performing a cardiac examination, it is important to consider rare cardiac pathologies such as HOCM. Adequate work up of HOCM includes evaluation of the left ventricular and septal size and mitral valve function. It is also important to screen the patient's first degree relatives for HOCM because of the autosomal dominant nature of HOCM gene mutations. Once appropriately diagnosed, treatment options are alcohol ablation or myomectomy of the hypertrophied septum. Prompt treatment is essential to minimize the risk of sudden cardiac death.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 A CASE PRESENTATION OF INTESTINAL CANDIDIASIS CAUSING IRRITABLE BOWEL SYNDROME AND PERIPHERAL NEUROPATHY(2013-04-12) Yu, LuPurpose: To demonstrate the role of candidiasis in Irritable Bowel Syndrome (IBS), investigate the possibility of intestinal candidiasis causing periphery neuropathy, and encourage clinicians to consider intestinal candidiasis in patients with symptoms of IBS. Methods: A clinical case of IBS with peripheral neuropathy is investigated. The 35yo man of Mediterranean descent complained of persistent diarrhea, diffuse abdominal pain, generalized myalgia, and parenthesis in extremities. Stools were loose, watery, foul smelling, and yellowish in color. There was no melena. He occasionally had constipation. Dicyclomine provided mild relief during episodes of severe diarrhea. Myalgias were most severe in lower lumbar region, radiating to his extremities. Tramadol provided moderate relief. He also felt weakness, numbness, and tingling in his face, hands and feet Symptoms had been waxing and waning for over 6 years, but worsened over the last year. 6 years ago, he was diagnosed with IBS after a negative EGD and colonoscopy (some evidence of diverticulosis). Results: Labs and imaging tests ruled out celiac disease, diabetes, thyroid disease, mineral deficiency, metal poisoning, autoimmune disorders, Lyme disease, syphilis, and structural abnormalities. The patient was advised keep a food diary. Over a month of carbohydrate and sugar restriction, he had significant relief of his symptoms. His abdominal pain and diarrhea had largely resolved since the diet change. He still experienced occasional parenthesis in extremities. Acquired carbohydrate intolerance due to intestinal candidiasis was suspected. He was treated with Diflucan for 30 days. Along with medication, he was also advised to supplement with probiotics and eat a healthy diet with continued carbohydrate and yeast restriction. The patient has remained symptom-free except for residual peripheral neuropathy since the treatment. Conclusions: Candida albican is a normal gastrointestinal microbial in healthy humans, but during immunosuppression or alteration of bacteria microbiota, such as following broad-spectrum antibiotic treatment or chronic vaginal candidiasis, C. albicans can overgrow and suppress the healthy bacterium of the colon, resulting in abdominal pain and diarrhea. It is also suspected that candidiasis can cause peripheral neuropathy due to overproduction of alcohol. Treatment is anti-fungal medication. A healthy, low-carb diet and probiotic supplements are also essential to maintain intestinal health and prevent recurrence.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 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 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 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 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 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 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 BILATERAL APPEARANCE OF ADIPOSE MEDIAL GASTROCNEMIUS MUSCLE - A CASE REPORT(2013-04-12) Lowry, DrewPurpose: The gastrocnemius is normally a strong muscle for ankle plantar flexion as part of the triceps surae of the calf. Its two heads originate from the medial and lateral femoral epicondyles, respectively and converge at the middle half of the posterior leg as contributions of the Achilles tendon inserting on the calcaneus. The purpose of this case report is to describe a rare bilateral appearance of adipose medial gastrocnemius. Methods: A routine dissection was conducted on an 82-year old Caucasian female cadaver whose cause of death was dementia. Results: Complete adipose replacement of the medial head of gastrocnemius muscle was identified on both left and right legs. The adipose tissue was observed through the entire course of the medial gastrocnemius muscle belly from its origin at the medial epicondyle of the femur to its point of convergence as the Achilles tendon at the middle of the posterior leg. A longitudinal incision along the medial head of the gastrocnemius revealed oblique directed adipose tissue arrangement in a superomedial to inferolateral direction. Furthermore, no muscular atrophy, abnormality, or variation was observed throughout the remaining cadaver. Conclusions: It is commonly accepted that aging, sedentary life style, neurodegenerative muscle disorders, and metabolic disorders contribute to the replacement of skeletal muscle by adipose tissue. Frequently these mechanisms involve white-adipose infiltration of the sarcolemma resulting in a decreased percentage of muscle tissue comparatively. According to previous studies, long chain fatty acid uptake into skeletal muscle has been observed in partial sections of muscle and is linked with the muscle-specific protein marker caveolin-3 (Vistisen et al., 2004, p.603). This case involves complete transformation of skeletal muscle into adipose of the medial head of the gastrocnemius bilaterally, as opposed to partial, unilateral, or total gastrocnemius muscle transformation. No additional abnormality or pathological muscular changes were noted from the cadaver. This conversion of skeletal muscle to adipose involving half of the gastrocnemius bilaterally has never been reported before. With a most updated, thorough literature review, more in-depth research is warranted for this phenomenon.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 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 EXTRARENAL WILMS' TUMOR: A RARE CASE PRESENTATION(2013-04-12) Kelley IV, JamesPurpose: Wilms' tumor is the most common primary abdominal neoplasm arising in the kidney in the pediatric population. However, Wilms' tumor arising outside of the kidney (extrarenal Wilms' tumor) is a highly rare occurrence. In this report, we present the case of a six-year-old girl who presented with a large midline pelvic and abdominal mass, which after extensive pathologic analysis was diagnosed as Wilms' tumor. To our knowledge, this is one of only a small number of cases reported of Wilms' tumor arising in the pelvis of a child. The purpose of this study is to bring attention to a rare presentation of a common tumor arising in children. Methods: This case was studied to demonstrate an uncommon presentation of a common childhood tumor, allowing the reader to better understand presentations of Wilms' tumor arising outside of the kidney. Literature review of other previous reports of extrarenal Wilms' tumor in children was used to compare and contrast the tumor sites, modes of therapy applied, and overall outcomes. Results: After extensive analysis of imaging and pathologic specimens, the patient was diagnosed with extrarenal Wilms' tumor. The patient was administered extensive chemotherapy prior to surgical removal (neoadjuvant chemotherapy) according to a standard regimen for Wilms' tumor. After responding well to the chemotherapy, the tumor was resected, after which additional chemotherapy was administered. Five years since the completion of treatment, the patient has had no recurrence of malignancy. Conclusions: Due to its rare presentation, along with lack of tumor markers, it can be very difficult to make the diagnosis of extrarenal Wilms' tumor without surgical exploration and careful pathologic analysis. This brings to light the significance of a comprehensive patient history and physical exam. Examination of this case, along with prior reports of extrarenal Wilms' tumor, suggests that when evaluating a child with a solid tumor arising in the abdomen and pelvis, extrarenal Wilms' tumor should be a consideration in the differential diagnosis.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 IMMATURE TERATOMA IN A 16 YEAR OLD PATIENT: A CASE REPORT(2013-04-12) Venkatesh, RatiPurpose: While immature teratomas are rare germ cell tumors, which can affect both males and females, this case presentation focuses on clinical presentation, treatment and management of a patient from onset of symptoms to initial treatment options and long-term goals. Methods: Material and information for this case presentation was gathered from medical records from the patient's chart at a family medicine clinic. Other research material was then used to compare current practice guidelines in the setting of this case. Results: Immature teratomas represent germ cell tumors that involve layers of ectoderm, mesoderm and/or endoderm. With the varied symptoms at presentation, the likelihood of malignancy and the importance of staging and grading, the treatment plan and prognosis for immature teratomas can be very involved. In the case of this 16 year old, the patient who presented with both incontinence and abdominal pain needed surgery and chemotherapy. Conclusions: This case report serves to discuss one patient's presentation, initial workup and treatment of an immature teratoma. Through exploration of current guidelines, treatment options and other research regarding immature teratomas, health care providers can better understand the varied forms of these cancers and how to best care for patients with an immature teratoma.Item LISINOPRIL-INDUCED HYPERPIGMENTATION(2013-04-12) Yang, RobertPurpose: For patients with hypertension, cardiovascular disease, and diabetes, lisinopril is a commonly prescribed angiotensin-converting enzyme (ACE) inhibitor. While known to have adverse cutaneous reactions such as pruritus and angioedema, we present a case of hyperpigmenting, desquamating rash in a 54 year-old African American woman. Methods: The information was gathered from patient chart review. Results: Upon discontinuation of lisinopril, the subject's rash resolved. Conclusions: For patients on ACE inhibitors, development of a hyperpigmenting, desquamating rash should considered an adverse cutaneous reaction.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 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 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.