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    DiGeorge Syndrome in a 32-year-old male: A Cadaver Study
    (2024-03-21) Chatta, Waleed; Dahl, Kaylee; Findley, Brennan; Flume, Hayden; Miguel, Kristen; Patel, Anjali; Shindler, Sydney; Menegaz, Rachel; Gonzales, Lauren
    Background: DiGeorge Syndrome (DGS) is one of the most encountered chromosomal syndromes in the population and is marked by the deletion of 22q11.2. Phenotypic expression varies widely between patients. Main features include cardiac and conotruncal abnormalities, craniofacial anomalies including cleft palate, thymic hypoplasia, hypocalcemia, and scoliosis. The branching pattern of the great vessels is known to be highly variable in DGS and a unique manifestation is found in this case. Case Information: This case report examines a 32-year-old deceased male with DGS, and a history of atrial fibrillation, pulmonary atresia-ventricular septal defect, pulmonary artery stenosis, pulmonary hypertension, and six heart surgeries. The cause of death was unspecified natural causes. Initial dissection of the thoracic cavity revealed clear signs of cardiomegaly and a severe scoliotic curve extending to the lumbar region. Further heart dissection revealed sutures and pericardial reconstruction confirming previous surgeries, likely to reconstruct the greater vessels. External findings include an aortic arch variant consisting of absent brachiocephalic trunk, a unique branching pattern of the great vessels directly from the aorta, and the wrapping of the proximal descending aorta around the trachea before descending. Pulmonary trunk adhesion to the heart's surface via scar tissue indicates surgical reconstruction. The left pulmonary artery was significantly constricted while the right pulmonary artery was expanded with immediate branching into smaller segments upon entering the lung, suggesting that more blood was shunted into the right lung. The right atrium appeared significantly enlarged with appropriate size compensations noticed in pectinate muscles and crista terminalis. The right auricle was small and only observable internally. The coronary sinus was abnormally enlarged, comparable in size to the opening of the inferior vena cava. Circular shaped scar tissue on the external surface of the sinus indicates a surgical correction. The right ventricle contained an abnormally enlarged moderator band. Dense scar tissue stenosis was visualized along the pulmonary outflow valve with sutures present along the entire circumference of outflow tract prior to pulmonary artery bifurcation indicating surgical reconstruction. Additional sutures were observed inferior to the circumferential sutures along the wall between the aorta and pulmonary trunk, potentially to seal a prior communicating shunt. The pulmonary veins and left atrium appeared normal; however, possible stenosis of the bicuspid valve was noted but further assessment is needed to confirm. The left ventricle showed enlarged papillary muscles and chordae tendinea which are hypothesized to be a byproduct of the overall increased heart size. The left ventricular wall was twice the thickness of the right ventricular wall, an expected proportion based on heart size and ventricular work. The aortic valves appeared slightly stenosed with cusp buildup. Coronary ostia appeared normal. Conclusion: This cadaveric case study reflects a unique cardiac presentation of DGS within an adult male. With DGS being a rather common chromosomal disorder with highly variable phenotypic expression, there is an importance to explore anatomical variants, their prevalence, and the needed surgical corrections present within patients to ensure that a more comprehensive diagnosis and care plan can be provided in future diagnostic settings.
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    An Unusual Case of Metabolic Acidosis- Mind the Gap!
    (2024-03-21) Choi, Jonathan; Moizuddin, Mohammed
    Background: Euglycemic diabetic ketoacidosis (EDKA) is a rare, life-threatening condition characterized by acidosis, elevated ketone levels, and a high anion gap (AG) in the presence of normal blood glucose. We present a unique case of EDKA in a non-diabetic patient linked to sodium-glucose cotransporter-2 (SGLT2) inhibitor use. Case Presentation: A 64-year-old female with a history of chronic hypercapnic respiratory failure, Charcot-Marie-Tooth disease, hypertension, depression, and chronic diastolic congestive heart failure was admitted for progressively worsening confusion, left-sided weakness, facial numbness, dyspnea, generalized weakness and feeling ill for 24 hours duration. Physical exam revealed afebrile, confused patient with bilateral lower extremity weakness. At home she was on Dapagliflozin, Metoprolol, Sacubitril-Valsartan, and Spironolactone. Laboratory results showed a glucose level of99 mg/dl, a bicarbonate level of 13 mmol/l, an AG of 18mEq/l, delta gap of 6mEq/l, arterial pH of 7.08, and PCO2 of 36. Urinalysis revealed leukocytes, positive nitrate, high glucose (>1000 mmol/l), ketones (>80 mmol/l), and beta-hydroxybutyrate (6.7 mmol/l). Computed tomography (CT) brain scan showed no intracranial hemorrhage. EDKA was diagnosed, and her treatment included intravenous dextrose, insulin, and broad-spectrum antibiotics for a urinary tract infection. She responded well to treatment, with resolution of her metabolic acidosis. Conclusion: The incidence of EDKA due to SGLT2 inhibitors is approximately 0.1%. Timely diagnosis can be challenging due to normal glucose levels. We know that SGLT2 inhibitors enhance glycosuria, promoting ketone body production through lipolysis. Elevated glucagon and reduced glucose levels contribute to hepatic ketone production. Increasing glucagon levels and low glucose levels promote the production of ketones, and this glucagon-insulin imbalance leads to the development of EDKA. Differential diagnoses for high anion gap metabolic acidosis (HAGMA) include methanol, uremia, diabetic ketoacidosis, propylene glycol, isoniazid, iron overdose, lactic acidosis, ethylene glycol, and salicylate toxicity. Initial laboratory assessments should include basic electrolytes, glucose, calcium, magnesium, creatinine, blood urea nitrogen, serum and urine ketones, beta-hydroxybutyric acid, arterial or venous blood gas analysis, lactic acid, and complete blood count, among others. Blood cultures, urine analysis, and chest radiographs are needed to rule out any infection. High-calorie glucose infusion and tight glycemic control are key elements in ameliorating intractable metabolic acidosis brought about by SGLT2 inhibitor-induced EDKA. Remember to always mind the gap in patients with HAGMA! Healthcare providers should remain diligent, considering EDKA, especially with normal glucose levels. Patients need to be educated about the risks associated with SGLT2 inhibitors, fostering open communication and shared decision-making for safer medication management.
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    Hypercholesterolemia Induced by a High-Fat, Low-Carbohydrate Diet in a 16-year-old Male and 6-year-old Female.
    (2024-03-21) Snyder, Alyssa; Hamilton, Luke; Wilson, Don
    Background: The ketogenic diet is a high-fat, low-carbohydrate (HFLC) diet that has been linked to hypercholesterolemia. There are ongoing studies on the connection between hypercholesterolemia and adherence to the ketogenic diet. Medically supervised HFLC ketogenic diets with up to 90% fat have been used successfully in children as an alternative treatment for epilepsy. Although safety and efficacy data are limited in children, this high-fat diet has also been used for weight loss. Case information: Patient 1:A 16-year-old previously healthy African American male was concerned about his weight and his mother started him on a ketogenic diet. Before diet implementation, he weighed 93.2 kg (BMI of 31.6 kg/m2; 99%) and had a low-density lipoprotein cholesterol (LDL-C) of 114 mg/dL (normal LDL-C is below 110 mg/dL). During the following months, the patient lost weight and his LDL-C levels continuously increased and peaked at 348 mg/dL after losing 59lbs on the ketogenic diet. The patient was offered pharmacotherapy but the parents declined. During his most recent follow-up appointment, the patient stopped adhering to the ketogenic diet and increased his weight to 79.2 kg (BMI of 26.2 kg/m2; 87.5%), and his LDL-C level dropped to 182 mg/dL. Throughout appointments, triglycerides remained normal. No pathological variants for APOB, LDLR, LDLRAP1, and PCSK9were found on genetic testing. Patient 2: A 6-year-old female with a history of idiopathic ketotic hypoglycemia and growth hormone deficiency was started on the ketogenic diet as a way to help control hypoglycemic episodes. The diet helped keep her blood glucose levels stable but she demonstrated severe hypercholesterolemia on her lipid screening. Her LDL-C levels were significantly elevated at 310 mg/dL 37 months after her first appointment. She was taken off the ketogenic diet for 6-8 weeks with significant improvement in her LDL-C dropping down to 116 mg/dL. At 42 months, the patient was admitted to the hospital for hypoglycemia. It was noted that the mother had started the patient on the ketogenic diet again due to recurrent episodes of hypoglycemia. On lipid screening, her LDL-C was back up to 397 mg/dL. Genetic testing for APOB, LDLR, LDLRAP1, and PCSK9 were all negative. Conclusions: Several mechanisms have been proposed to explain the adverse effect of hypercholesterolemia in individuals participating in the ketogenic diet. This includes increased saturated fatty acid intake causing downregulation of LDL receptors, genetic polymorphisms, and cholesterol mobilization associated with weight loss. Although there is ongoing research regarding the mechanism behind hypercholesterolemia associated with HFLC diets, there is no clear, definitive explanation yet. Our case study and other case series in adults on the ketogenic diet for weight loss show the importance of ruling out HFLC diets when patients present with hypercholesterolemia and have no known genetic mutations suggesting familial hypercholesterolemia (FH).
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    Pseudopheochromocytoma: A Case of Benign Endothelial Cyst of the Adrenal Gland
    (2024-03-21) Nguyen, Antoine; Tamayo, Jesus; Mohammad, Moath; Paluru, Swetha
    Background: Benign endothelial cyst of the adrenal gland (ECAG) with pheochromocytoma-like symptoms, or pseudopheochromocytoma (pseudoPHEO), is an extremely rare condition. Adrenal cysts seldomly occur with an incidence of 0.06% in the general population. Most cases are asymptomatic and discovered incidentally on imaging. ECAG predominately affect females and represent approximately 45% of all cystic tumors involving adrenal glands with two subtypes: angiomatous and lymphangiomatous. The association of adrenal cysts with pseudopheochromocytoma is a rare but well-documented relationship. Occasionally, these cysts can increase pressure in the adrenal medulla leading to elevated metanephrine levels. PseudoPHEO is a diagnosis of exclusion with pheochromocytoma being an important differential diagnosis. Patients may present with pheochromocytoma-like features such as symptomatic paroxysmal hypertension. If adrenal cortical tumors are involved, elevated catecholamines can be found on evaluation, although catecholamine-secreting tumors are diagnosed in less than 0.5% of patients with hypertension. Case Information: A 63-year-old female with a past medical history of an adrenal nodule discovered in 2017 during colon resection and poorly-controlled hypertension presented for adrenalectomy for suspected pheochromocytoma. Her normetanephrine level was 342 (normal: <148pg/mL) and metanephrine was 50 (normal: <57pg/mL). CT of the abdomen demonstrated an adrenal lesion with some features of benign etiology. She underwent robotic-assisted laparoscopic right adrenalectomy during which a 3 cm cyst in the adrenal medulla was found abutting the adrenal cortex. Microscopically, a multilocular cyst associated with hemorrhage involving the adrenal medulla was present. Conclusion: To diagnose pseudoPHEO, pheochromocytoma must be excluded especially when symptomatic paroxysmal hypertension is present with or without elevated catecholamines. The cells were positive for CD31 and negative for calretinin on immunohistochemistry staining which support an endothelial cell origin consistent with benign ECAG, not pheochromocytoma. These cysts may occupy space in the adrenal gland, increasing pressure in the adrenal medulla to cause elevated metanephrines, as seen in this patient. While the prognosis for ECAG is good, ECAG with associated pseudopheochromocytoma can cause life threatening complications. Treatment of pseudoPHEO is dependent on severity and etiology of disease process. Medical management can be complicated by unpredictable episodes of hypotension as patients can be normotensive between symptomatic episodes. In cases of pseudopheochromocytoma caused by ECAG, adrenalectomy is often indicated.
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    Nutritional Management of IBS-complicated Exercise-Induced Gastrointestinal Syndrome
    (2024-03-21) Wu, David; Farmer, Madison
    Background: The mechanism behind exercise-induced gastrointestinal syndrome (Ex-GIS) causing abdominal pain related to exercise is proposed to be due to altered gastrointestinal blood flow and neuroendocrine changes. Ex-GIS is found in up to 70% of athletes performing intense endurance exercise and can imitate the symptoms of Irritable Bowel Syndrome (IBS). However, the availability of research addressing the coexistence of IBS and Ex-GIS in athletes is limited. This is complicated by the underreported and underdiagnosed nature of IBS. Case Information: A 24 y/o male recreational triathlete presented with a chief complaint of chronic gastrointestinal distress both during and after endurance exercise. He described his abdominal pain as crampy with an excessive amount of bloating. High intensity long-distance running exacerbated his pain, but he obtained minor relief using OTC loperamide HCl 2mg with simethicone 125mg PRN and also by ceasing physical activity. Past medical history included painless hematochezia and Irritable Bowel Syndrome-Mixed (IBS-M). He endorsed consuming a high FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet of poorly digestible carbohydrates and lactose-intolerance that was poorly controlled with the inconsistent use of lactase enzyme supplements. On physical exam, the patient appeared well and was in no acute distress. The only physical exam findings were hyperactive bowel sounds on abdominal auscultation. The differential diagnoses included IBS, Ex-GIS, and Ex-GIS complicated by comorbid IBS. The patient received a colonoscopy in 2021 to rule out lower GI pathology. The colonoscopy results indicated internal hemorrhoids, which could help explain the painless hematochezia. However, the biopsy results and gross examination were otherwise normal. As a result, the patient received a diagnosis of IBS-mixed, by exclusion, and the patient was prescribed dicyclomine 10mg twice daily, but has been non-compliant due to unfavorable side effects. Searching for a non-medication based treatment, the patient turned towards dietary and behavioral modifications to seek relief. Preliminary research suggests that endurance athletes routinely eat up to 43g of FODMAPs/day, nearly twice the recommended amount, and that athletes suffering from Ex-GIS should consume a low FODMAP diet of 5-18g/day. Additionally, athletes who have Ex-GIS complicated by IBS should further reduce their FODMAP intake to under 3g/day. Conclusions: This case represents a unique presentation of exercise-induced gastrointestinal syndrome, further complicated by IBS symptoms. By consuming a low FODMAP diet, patients may be able to obtain significant symptom relief from IBS-complicated exercise-induced gastrointestinal syndrome. However, more research needs to be completed to address the dichotomy of high FODMAP foods being beneficial for athletic performance, while exacerbating symptoms in patients suffering from IBS-complicated Ex-GIS.
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    Iatrogenic Corticosteroid Atrophy Mimicking Bilateral Morphea en Coup de Sabre: A Case Report
    (2024-03-21) Do Valle, Rafael; Wong, Christopher; Pool, Jade; Kenny, Cassandra; Wilkes, Dustin
    Background: Corticosteroids affect numerous downstream cytokines to exert anti-inflammatory and immunosuppressive effects. Intralesional corticosteroid injection provides several advantages, including bypassing the stratum corneum to deliver a higher concentration of drug locally, while reducing systemic exposure. Intralesional corticosteroids are used in a variety of dermatologic conditions, and suboccipital steroid injection has been described as a novel treatment for cluster headaches. Case Presentation: A 52-year-old Caucasian female presented to the outpatient dermatologic clinic with indented skin lesions on the scalp and forehead for six weeks. The indentation started on her left frontal scalp and spread down gradually to her forehead and temple. She later noticed the same indentation appearing on her right side. She reported severe pain and the “worst headache” before the lesions started, but there was no further pain after the lesions appeared. Dermatologic examination demonstrated two symmetric hypopigmented linear atrophic plaques extending from the lateral forehead to the frontoparietal scalp on each side. A punch biopsy from the left superior central forehead showed epidermal atrophy with compact orthokeratosis, and scattered telangiectasias within the papillary dermis. Elastin van Giesonstaining demonstrated a loss of elastic fibers in the papillary dermis. There was no dermal sclerosis. The adnexal structures, CD34 expression, and the elastic component of the reticular dermis were intact. Direct immunofluorescence studies were negative. Upon further questioning, the patient revealed that she had injections with an unknown medication to the occipital and frontal scalps due to severe headaches from a motor vehicle accident. A diagnosis of steroid-induced skin atrophy was made from clinicopathologic correlation. Conclusions: The adverse effects related to intralesional corticosteroid injections include hypopigmentation, telangiectasias, striae, and atrophy of the skin and subcutaneous fat. When present on the frontal and temporal scalp, atrophic plaques can mimic morphea en coup de sabre, a form of linear localized scleroderma with an autoimmune etiology. Several cases of bilateral morphea en coup de sabre have been previously reported. This case study highlights the importance of obtaining a comprehensive patient history in formation of a differential diagnosis. It also showcases the potential complications of intralesional corticosteroid injections, emphasizing the informed consent process for patients to fully understand possible adverse effects from treatment.
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    Case report: rapid development and progression of duodenal varices without significant change in existing esophagogastric varices
    (2024-03-21) Phu, Daniel; Phillips, Wendy; Nguyen, Elizabeth; Hoang, Long
    Background: Duodenal varices (DV) are a rare complication of portal hypertension, leaving the topic relatively unexplored. There are some reports describing the presence of and potential treatments for DV, but little is known about their progression. Below we present an interesting case of a patient with portal hypertension who developed and had rapid progression of DV without any progression of her existing esophageal varices (EV). Case Information: The patient had an esophagogastroduodenoscopy (EGD) which showed non bleeding grade 1 esophageal varices and no other abnormal findings.2 years later, the patient underwent an EGD which showed non bleeding grade 1 varices found in the lower third of the esophagus. Further inspection revealed large non bleeding varices in the second portion of her duodenum. Conclusions: Although rarer than EV, bleeding from DV is often difficult to diagnose and even harder to control, leading to mortality rates up to 40% for initial bleeding. Otherwise, there is little data comparing the pathophysiology and outcomes of EV and DV. We hypothesize that the rapid development and progression of DV without any significant change in EV may be related to 1) increased flow toward the duodenum and away from the esophagus, 2) increased propensity for duodenal anastomoses to dilate, or 3) anatomical variants not previously identified or studied. As our understanding of DV grows, diagnostic and therapeutic algorithms may need to be adjusted to account for ectopic varices other than EV and to more effectively allocate beta blocker prophylaxis in patients with portal hypertension.
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    Comparing Balance in Patients with Fall History
    (2024-03-21) Roccaforte, Emma; Wahl, Joseph; McGrath, Jessica; Kennedy, Shawn; Patterson, Rita M.
    Purpose: With falls being the leading cause of mortality with injury, risk factors of falls should be explored further (Lohman). Postural Sway is a method in which you can quantify balance and postural control. Increase in postural sway is shown to be correlated with error in postural control modalities. (Dewan). Having a quantifiable fall-risk metric that can be quickly obtained, could prevent falls, and thereby reduce mortality and surgical interventions necessary. This experiment explores the effect of fall history on postural sway using the Bertec force plate’s measurement of change of pressure, CoP. Methods/Materials: Family Medicine and Geriatric patient participants on a volunteer basis were asked to perform two 30 second intervals of quiet standing on a Bertec force plate as an additional vital sign. Two conditions were performed on firm surfaces: with eyes open (EO) and with eyes closed (EC). Patients were asked to stare at a target for the EO portion and stand still on the force plate for 30 seconds while data was collected. After this, the patient was asked to close their eyes and stand still for another 30 seconds for the eyes closed portion. Postural sway was measured in accordance with CoP using the Clinical Test of Sensory Integration and Balance (mCTSIB) protocol, which describes quiet standing under various conditions to assess fall risk and balance problems. A group of 22 patients with a documented history of a fall was compared against 129 patients without a documented history of a fall. The values of the Range of the CoP in anterior-posterior (AP) direction/axis and medial-lateral (ML) direction/axis were compared using a 2-tail T-test. The values of standard deviation and average of the Radial Distance (RD), the displacement of the CoP points from the center of the stabiligram, a graphical representation of the movements of a person’s quiet standing, were also compared using a 2-tail T-test. Significant values at both conditions, EO and EC, were noted at p < 0.05. Results: The Range of the CoP (AP) was significantly increased in both conditions, EO and EC. The Range of the CoP (ML) was significantly increased in EC, but nonsignificant in EO. The Average RD was significant in EC but nonsignificant in EO, with the Standard Deviation RD with a significant increase in both EO and EC. Conclusion: These findings suggest that there is increased sway in patients with a reported history of a fall compared to those without. This could be a result of error in the vestibular, somatosensory, or visual systems. These errors could point to an increased fall risk. Future studies should investigate the effects these systems have on fall risk as there was more consistent statistical difference of the groups during the eyes closed portion. Some limitations include small sample size, other factors altering sway, and potential non reported fallers in the control group. The ability to measure fall risk quickly and objectively through a simple and non-invasive method like postural sway could prove instrumental in preventing falls with further studies.
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    The Art of Diagnosis: Cyto-Histopathological Correlation in Metastatic Lung Cancers - A Rare Case Report
    (2024-03-21) Peddireddy, Navya
    Background Metaplastic breast carcinoma (MBC), an exceptionally rare and heterogeneous triple-negative subtype of breast cancer, accounts for less than 1% of all breast carcinomas. This case report exemplifies the pivotal role of cytohistological correlation in diagnosing lung metastasis through fine needle aspiration biopsy. The case of a 90-year-old female with a complex medical history is presented, highlighting the importance of careful clinical assessment in metastatic lung cancers. Case Information A 90-year-old female, with a history of metaplastic breast carcinoma following a left mastectomy 20 months ago, was admitted due to a four-week history of progressive dyspnea and fatigue. Despite being a non-smoker, she had a history of essential tremor, dementia, and chronic obstructive pulmonary disease. Extensive diagnostic evaluations, including laboratory results and imaging, revealed pulmonary nodules and partially calcified pleural masses bilaterally along with pleural effusions, raising concerns of metastasis. Thoracentesis initially showed negative pathology findings, along with subsequent CT-guided lung biopsies, prompting an investigation into the patient’s prior oncology history. The patient's past oncology reports were revisited, uncovering a diagnosis of metaplastic carcinoma with mesenchymal differentiation in the breast. Cytohistological correlation was performed, ultimately confirming the presence of malignant cells in the lung biopsy, leading to the diagnosis of stage IV triple-negative metaplastic breast carcinoma with malignant pleural effusion. Conclusions Metaplastic breast carcinoma is characterized by the differentiation of malignant cells toward mesenchymal and squamous elements, making it a rare and heterogeneous cancer. The patient's case, with lung metastasis originating from a metaplastic breast carcinoma, is a rare occurrence, further emphasizing the importance of accurate diagnosis in such unique situations. The report underscores the significance of meticulous medical history collection, interdisciplinary communication, expert consultation, and cyto-histopathological correlation in achieving accurate pathological and clinical diagnoses in metastatic lung cancers. Metaplastic breast carcinoma's rarity and heterogeneity contribute to its generally poor prognosis, with factors like advanced age, high-grade tumors, and distant metastasis reducing survival rates. In most cases, surgical resection remains the primary treatment approach, followed by platinum-based chemotherapy. Promising treatment avenues, including immunotherapy and molecular targeted therapies, may improve patient outcomes, but these options depend on individual circumstances. In the case presented here, the patient's age and comorbidities influenced the decision to opt for hospice care, highlighting the importance of tailoring treatment strategies to a patient's unique situation. This case report not only sheds light on a rare occurrence but also serves as a reminder of the importance of comprehensive medical assessments in managing complex clinical scenarios.
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    Tracheobronchopathia Osteochondroplastica Presenting as Acute Shortness of Breath
    (2024-03-21) Qadri, Syed; Pratka, Holden; Schultz, Steve
    An outpatient case of tracheobronchopathia osteochondroplastica is reported in a 58-year-old male presenting from the Dallas-Fort Worth area. Tracheobronchopathia osteochondroplastica (TO) is an exceedingly rare, non-neoplastic tracheobronchial condition characterized by multitudinous sessile, cartilaginous nodules, most prominent along the anterolateral walls and projecting into the lumen of the trachea and bronchi (Silveira et al 2017). Here we highlight the case of a middle-aged male presenting to the outpatient clinic with acute shortness of breath and cough. Chest CT without contrast was promptly ordered, displaying anterior and lateral endotracheal submucosal nodularity. Subsequent bronchoscopy confirmed the diagnosis of TO. Diagnosis and management of this condition is limited by clinicians' lack of familiarity with this pathology. Unfortunately, because of its rarity and potentially broad array of presenting symptoms, diagnosis may often be delayed resulting in increased stress for the expectant patient. The time between first symptoms and ultimate diagnosis is about 4 years in most cases; however, can be greater than 25 years according to some reports (Jabbardarjani et al 2008). Radiographically, tracheobronchopathia osteochondroplastica can look similar to other conditions in the trachea such as relapsing polychondritis, granulomatous processes such as granulomatosis with polyangiitis, and sarcoidosis. Amyloidosis, inflammatory bowel disease, and certain infectious processes should be considered as well. As such, the purpose of this case report is to increase clinical awareness of this rare condition to potentially expedite its management and diagnosis.
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    A Rare Case of Paraumbilical Hernia Containing and Obstructing the Stomach
    (2024-03-21) Martinez, Maria Francesca Ysabelle; Prado, Cynthia; Cao, Ngan; Ngo, Wayne; Salinas, Miguel; Maheshwari, Mukul
    Background: Abdominal hernias occur when peritoneal lined organs protrude through the abdominal wall. They are common with an estimated prevalence of 25% in adults. Patients may be asymptomatic but surgical intervention may be advised if patients are at risk for complications such as incarceration and strangulation. Initial diagnosis of abdominal hernias is made clinically but may be assisted with imaging. Computed tomography (CT) is the current modality of choice. In this case report, we specifically focus on midline abdominal hernias. These include epigastric, paraumbilical, umbilical, and hypogastric hernias. The most frequent abdominal hernia is the paraumbilical/umbilical hernia which account for 13.9% of all hernias. These occur due to weakness or defect in the linea alba and/or abdominal rectus muscles. Patient presentation varies but many have a visible bulge that may or may not be tender to palpation. Typical contents of paraumbilical/umbilical hernias include peritoneal fat, omentum, small bowel, and large bowel. We present a unique case of stomach herniation into a pre-existing ventral abdominal hernia that has been described only a few times in the last century. Identification with CT allowed for appropriate anatomical resolution to assess for bowel obstruction and strangulation of hernia contents. Case Presentation: A 72-year-old female presented to the emergency department with abdominal pain, nausea, and emesis. Prior computed tomography (CT) studies completed one month before presentation showed a large, ventral abdominal paraumbilical hernia without obstruction or strangulation. However, one month later she presented with worsening symptoms of abdominal pain, nausea, and emesis. Repeat abdominal and pelvis CT showed interval herniation of the distal stomach and proximal bowel into the patient’s known paraumbilical hernia. This resulted in gastric outlet obstruction. Immediate management included intravenous fluids, nasogastric tube placement and surgical correction. Operative report revealed a large ventral abdominal hernia with viable stomach, proximal duodenum (D1), cecum, ascending and transverse colon, and multiple loops of small bowel without evidence of strangulation. The patient successfully recovered after surgery. Conclusion: A rare complication in paraumbilical/umbilical hernias is gastric herniation into an existing hernia. Patients may present with red flag symptoms such as abdominal pain, nausea, and emesis. Quick identification of these symptoms and rapid visualization with CT will help identify the extent of herniation and other complications such as bowel obstruction, strangulation, and incarceration. A major risk factor for gastric herniation is weakened abdominal muscles and increased laxity of stomach ligaments found in populations such as multiparous women of middle to late ages. Healthcare professionals should be aware of patients who fit this demographic to educate them on the risk of herniation and recommend them for prophylactic surgical treatment.
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    Tapinarof-Induced Folliculitis Outside of Treated Psoriasis Plaques: A Case Report
    (2024-03-21) Martinez, Maria Francesca Ysabelle; Scheufele, Christian; Weis, Stephen
    Background: Tapinarof 1% cream is a novel non-steroidal topical medication recently FDA-approved for plaque psoriasis. Plaque psoriasis is a chronic inflammatory skin disorder that manifests as erythematous plaques with micaceous scale on the body, often associated with pruritus. Appearance and symptoms of the plaques can greatly impact patients’ quality of life. Tapinarof’s non-steroidal mechanism allow for longer treatment periods without topical corticosteroid side effects e.g. skin atrophy, hypopigmentation, telangiectasia, and striae. Adverse events identified during pivotal trials may not be completely defined before widespread clinical use. This case reports a new presentation of folliculitis with tapinarof use. Case Presentation: A 25-year-old female with trisomy-21 presented for a rash on her left lower leg. The eruption began one year earlier. The eruption was not associated with pruritus, joint pain or nail changes. A clinical diagnosis of plaque psoriasis was made. Due to unsuccessful response with topical steroids and topical vitamin D analogues, alternative treatment was started with topical tapinarof. After approximately two months of treatment, the patient presented with a new concern of an itchy rash. On exam she had follicular papules around the original plaque. In addition, she had follicular papules and pustules following a linear distribution ascending the affected leg. These papules were distant from the original eruption. There were similar scattered papules on the unaffected leg. A clinical diagnosis of folliculitis was made. Bacterial and fungal cultures were negative. A biopsy demonstrated folliculitis and special stains did not show organisms. Conclusion: Tapinarof cream is a novel non-steroidal treatment option for plaque psoriasis. Tapinarof is considered by many to have a better safety profile when compared to topical steroids. Adverse events reported in tapinarof clinical trials included folliculitis at or near the site of psoriatic /plaque. This case is unique as the folliculitis occurred not just at the site of application, but also occurred distant to the site. The distribution has not been previously reported. Our case provides histological confirmation of folliculitis as a side effect. This unusual distribution of folliculitis may be due to external factors such as transfer of the medication by bed sheets or clothing. An alternative theory may be scratching of the plaque then subsequent spread to the areas where folliculitis is now evident. Further experience with tapinarof will more completely define tapinarof associated folliculitis. In the meantime, clinicians treating patients with tapinarof who develop folliculitis need to consider this possibility in their differential diagnosis.
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    Complications Beyond Borders: A Case Study on a Retained Surgical Towel Leading to an Intra-Abdominal Abscess Post-Hysterectomy
    (2024-03-21) Oldham, Jake; Judd, Dallin; Hawes, Jaden; Stucki, Brenton; Boyack, Bryant
    Background: The advancement of surgical techniques and procedures has dramatically improved healthcare outcomes globally. Despite these advancements, surgical interventions inherently carry the risk of complications, some of which can be severe and life-altering. Case Presentation: This report details a severe complication following a hysterectomy performed in Mexico on a 46-year-old woman, who developed an intra-abdominal abscess due to a retained surgical towel—a rare but grave surgical error. Initially, her post-surgical symptoms, including abdominal pain, fever, and malaise, were dismissed by her surgeon in Mexico as typical recovery effects. However, as her condition deteriorated, she sought emergency care in Arizona. A CT scan unveiled a significant abscess in her abdomen, marked by a radio dense ribbon indicative of the forgotten surgical towel. Emergency intervention was necessary to extract the towel and address the abscess, further complicated by the discovery of a multi-drug resistant organism. Conclusion: This incident highlights the paramount importance of adhering to surgical safety standards, the potential hazards of seeking medical procedures abroad, and the necessity for diligent postoperative monitoring and open communication between patients and their medical teams.
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    Elevated Troponins in a Middle-Aged Male Presenting with Cough, Dyspnea, and Chest Pain
    (2024-03-21) Bautista, Trissha Belle; Gulley, Taylor Cemone; Segovia, Alicia
    Background: Respiratory complications from SARS-CoV-2 infection are most commonly reported; however, adverse cardiac events such as acute coronary syndromes, thromboembolic syndromes, and myocarditis have been described. A study by the Centers for Disease Control estimates an overall incidence of COVID-related myocarditis to be at around 150 cases per 100000 individuals in the United States. Case Presentation: A 45-year-old male with a past medical history of exercise-induced asthma, obstructive sleep apnea, and gastroesophageal reflux disease was admitted to our hospital from the emergency department due to chest pain, shortness of breath on exertion, and cough. Patient reports having a cough that started three days prior to ED presentation. He managed his cough conservatively over the weekend, but his symptoms increased in severity and he developed a headache and chest pain radiating to his neck and jaw. Upon presentation to the ED, patient endorses the chest pain to be resolved. His vitals at the ED were temperature 97.8F, HR 97, RR 16, BP (MAP) 121/82 (95), O2 96% on room air. At the ED, his electrocardiogram showed ST depression in leads III and aVF, but no ST elevations to suggest STEMI. Initial workup shows unremarkable electrolytes, mild hyperglycemia with glucose 119 mg/dL, mild transaminase elevation with ALT 46 IU/L and AST 46 IU/L, and elevated troponin 0.308 ng/mL (normal: 0.00-0.013 ng/mL). Patient also tested positive for SARS-CoV-2 via rapid test. Serial troponins were monitored in the ED and rose to 0.910 ng/mL then 4.446 ng/mL before admission to inpatient floor. No radiographic evidence of acute pulmonary disease was identified. ACS protocol was initiated and patient received dual antiplatelet therapy, heparin, and metoprolol/lisinopril. Cardiology was consulted and an echocardiogram was performed which showed normal chamber sizes, normal left ventricular systolic function, and mild concentric left ventricular hypertrophy. Due to patient’s stable clinical presentation and echocardiogram results, the cardiologist recommended serial troponin measurements and felt that a stress test was not indicated. Troponins continued to trend upward to 16.7 ng/mL two days later. Conclusions: This case highlights the cardiac manifestations of COVID-19 in a patient with stable clinical presentation and markedly elevated troponin levels. The magnitude of troponin elevation in hospitalized patients with COVID-19 is typically associated with worse outcomes; however, this case illustrates the wide array of clinical cardiac presentation in patients with COVID-19-related myocardial injury.