Case Presentation

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NON-OPERATIVE MANAGEMENT FOR A NON-UNION CUBOID FRACTURE
(2014-03) Bodenhamer, Sara; Kelley, James J.; Clearfield, Daniel
The authors describe the case of a 30-year-old female who presented with right foot pain after a trampoline injury. She was diagnosed with a closed, slightly displaced avulsion fracture of the right cuboid and was managed conservatively. Initial conservative management failed, however after two months of continued electrical bone stimulation and immobilization, bony union with osseous bridging was apparent on imaging. The patient was able to avoid surgery and began a rehabilitation program. This case highlights the use of electrical bone stimulation in the management of a non-union cuboid avulsion fracture. Purpose (a): In this report, we assess electrical bone stimulation in the management of a non-union cuboid avulsion fracture in place of surgical intervention in a 30-year-old female. Methods (b): We reviewed the patient's medical record and imaging to provide a summary of the case presentation and X-ray findings. Review of the literature was also conducted to research the use of electrical bone stimulation in non-union fractures. Results (c): The patient was diagnosed with a closed, slightly displaced avulsion fracture of the right cuboid and was managed conservatively. Initial conservative management failed, however after two months of continued electrical bone stimulation and immobilization, bony union with osseous bridging was apparent on imaging. The patient was able to avoid surgery and began a rehabilitation program. She has since made a full recovery. Conclusions (d): Electrical bone stimulators can serve to enhance healing conservatively, and in cases that are recalcitrant to other modes of conservative therapy. Bone stimulation also provides a less invasive, less costly option leading to decreased morbidity. The use of bone stimulation in non-healing fractures may enhance and expedite the healing process. Conduction of larger studies and on various bones is necessary to assess the efficacy of this treatment and to fully utilize this management option in the future.
GENETIC POLYMORPHISMS AFFECTING CLOPIDOGREL METABOLISM
(2014-03) Jain, Adityanant; Bruchetta, Humberto
49 yo Asian male with history of coronary artery disease, hyperlipidemia, complete heart block, unstable angina pectoris and gout presents with four prior myocardial infarctions within the prior year indicating rapid stent restenosis despite being on dual anti-platelet therapy with clopidogrel and aspirin. Family history is very positive for myocardial infarctions and death on his paternal side. Patient is a lifetime non-smoker, employed as a hospital pharmacist and had no other cardiac risk factor besides family history. Physical exam was unremarkable, BMI 24.84, vital signs all normal. LDL was above goal at 83 and HDL was 61. A lipoprotein subfractionation, apolipoproteins, inflamatory markers, and genetic markers including LPA Aspirin, KIF6 Genotype, and CYP2C19 were obtained. Patient was noted to be homozygous KIF6 Arg/Arg and CYP2C19*2/*2. KIF6 Arg/Arg is associated with HR 1.50 for recurrent MI by the CARE trial, and clopidogrel is a pro-drug that requires CYP2C19 activation to be efficatious. The patient was changed to ticagrelor which has similar efficacy however does not require CYP2C19 activation. This case study strongly indicates a potential benefit for genetic screening for CYP2C19 on patients being placed on dual antiplatelet therapy with clopidogrel and aspirin. Further it shows the value of research in basic sciences to understand the causes variable responses to drugs in vivo. Purpose (a): To demonstrate a case of severe cardiovascular complications in a young and otherwise healthy patient with no high risk behaviours likely due to a genetic polymorphism affecting his ability to activate clopidogrel. Methods (b): Labs were drawn in the office and performed by Quest Lab and results were discussed with the patient who participated in decision making regarding his subsequent medication selection. Results (c): HR = "High Risk" LR = "Low Risk" MR = "Medium Risk," LPA Aspirin Genotype Ile/Ile (non-carrier), KIF6 Genotype Arg/Arg (High Risk-CV disease), 9p21 rs10757278 ag, 9p21 rs1333049 gc, ApoE Genotype E2/E3 (Apo E2 carrier), LPA Intron 25 Genotype tt (non-carrier), CYP2C19 *2/*2 (poor metabolizer), 4q25 AF Risk Genotype, rs2200733 tt (High Risk carrier - Afib & CVA), rs10033464 gg (non-carrier), HS-CRP 0.5, LP PLA2 181(LR), Fibrinogen Antigen 267 ≤ 350 (LR), Vitamin D, 25-OH, Total 18 ≥ 30 (HR), Vitamin D, 25-OH, D3 18, Vitamin D, 25-OH, D2 <4, Homocystine 16.1, Apolipoprotein A1 166 >176 (MR), Apolipoprotein B 62(MR), Apolipoprotein B/A1 0.37, Lipoprotein (a) 46(LR), Lipoprotein Subfractionation, LDL Phenotype A (LR), LDL, Particle Size 225.6 (LR) >255.5, LDL Particles, Tot 1234 (LR) <1260, LDL, Very Small 304 (LR) <398, LDL, Med & Small 397 (MR) <369, HDL, Small 28160 (LR) >28133, HDL, Large 8028 (MR) >9386, IDL, Small 223 (HR) >315, IDL, Large 179 (LR) <198, VLDL, Small 72 (LR) <124, VLDL, Medium 46 (LR) <61, VLDL, Large 13 (LR) <17. Conclusions (d): Our patient had multiple risk factors for underlying cardiovascular disease – including his KIF6 Arg/Arg genotype and strong family history. Although his CYP2C19*2/CYP2C19*2 genotype was not responsible for his underlying disease; significant evidence exists demonstrating that loss of function mutation being associated with adverse cardiovascular outcomes while on clopidogrel. Currently gene testing is not currently standard of care. Previous studies have not categorically shown cost-effectiveness of gene testing, however genetic testing technology is becoming increasingly affordable. Cost-effective gene testing and the availability of alternatives to clopidogrel suggests that identification of patients with loss of function mutations is in the best interest of patient care. If a patient has a thrombotic event on clopidogrel, it is appropriate to either determine CYP2C19 genotype or empirically initiate alternative antiplatelet therapy.
POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME (POTS): SYMPTOMS, SCREENING, AND USING AN EXERCISE PROGRAM TO IMPROVE ACTIVITY TOLERANCE IN A YOUNGER FEMALE
(2014-03) Richardson, Mike; Nordon-Craft, Amy; Carrothers, LeeAnne
The incidence of Postural Orthostatic Tachycardia Syndrome (POTS) is estimated to be 500,000 to over one million individuals in the United States and most commonly occurs in younger females. The recognition and management of POTS have increased over the past 20 years. The most common symptoms of POTS include light-headedness or dizziness, palpitations, fainting, near-fainting, intermittent muscle weakness (commonly in the legs), and fatigue after moving from lying down to standing. These symptoms occur in patients with POTS due to an abnormally rapid heart rate response cause by the change in position to standing. Lightheadedness, dizziness and/or near syncope after standing are classic symptoms with orthostatic hypotension. These symptoms also occur in patients with POTS. Most clinicians will monitor blood pressure at 1 and 3 minutes after standing to screen for orthostatic hypotension but will not monitor heart rate for 10 minutes during quiet standing to screen for POTS. Current research has demonstrated effectiveness of aerobic programs lasting 30-45 minutes per sessions, 2-4 times per week over 8-12 weeks. The researchers slowly progressed the subjects from semi-recumbent aerobic activities (recumbent biking, rowing, or swimming) to upright aerobic activities (upright biking, walking, or jogging) as long as the subjects remained symptom-free. The researchers initial strategy of avoiding upright activities allowed the subjects time to improve overall fitness levels without triggering the symptoms of POTS. The strength training followed the same pattern of semi-recumbent exercises (mat and chair) to upright exercises (standing.) The strengthening sessions were initially once weekly for 15-20 minutes and increased gradually to twice weekly for 30-40 minutes per session as tolerated by the subject. This case report describes the symptoms and screening for POTS, an evidence-based physical therapy intervention consisting of aerobic and strengthening components, and lifestyle modifications for a 34-year-old female who had experienced an exacerbation of POTS symptoms. This case report showed clinically significant changes (from the patient’s perspective) consistent with the previous research. The patient had steady improvements with her estimated VO2max testing at the discharge (4 weeks after the evaluation) and continued improvement at 8 weeks post discharge. The patient’s goals of improved work and life tolerance were achieved. A physical therapist must be able to recognize the symptoms of POTS and perform POTS screening as part of the differential diagnosing process. A patient could be suffering from undiagnosed POTS and present in a variety of different physical therapy settings with a variety of different diagnoses commonly seen by physical therapists such as: Chronic Fatigue Syndrome, muscle weakness, deconditioning, difficulty walking, vestibular issues, and migraines. Purpose (a): Postural Orthostatic Tachycardia Syndrome (POTS) is most prevalent in younger females and shares common symptoms with orthostatic hypotension (OH). Whereas the screening criteria for OH are well known in the physical therapy community, the symptoms and screening for POTS are not. The purposes of this case report were to: 1. describe the symptoms and current POTS screening guidelines, 2. address the role of the physical therapist in prescribing an effective exercise program. Methods (b): A 34-year-old female completed a 4-week course of physical therapy consisting of aerobic and strengthening exercise with an 8-week follow up after an exacerbation of POTS. Initial presenting symptoms included: dyspnea with mild exertion, light-headedness, fatigue, “heaviness” in her legs, and the inability to perform normal work duties. Results (c): The patient’s estimated VO2 max on the 1 mile timed walk test (1 MWT) improved from the 60th percentile at baseline to the 90th percentile at 8 weeks post discharge follow-up. In addition, the patient was able to return to work full time and resume all previous fitness activities. Conclusions (d): The patient demonstrated clinically meaningful improvements in estimated VO2max after the ‘reconditioning’ training. Physical therapists must be able to recognize the symptoms of and screen for POTS as part of a differential diagnosing process. Further research is needed with clinical trials to investigate the efficacy of other similar treatment strategies for POTS management.
ADULT ANNULAR PANCREAS: A CASE REPORT
(2014-03) Yurvati, Albert; Jeyarajah, D. Rohan; Patel, Shirali; Jacob, Rhema S.
Annular pancreas is a rare congenital abnormality, more often seen in the pediatric patient population. This abnormality results from failure of the ventral pancreatic bud during normal migration during development. Ectopic pancreatic tissue persists, encircling the duodenum. Hence, this can lead to duodenal obstruction. Despite the fact that annular pancreas is extremely rare in an adult patient population, annular pancreas deserves to be a part of a clinician’s differential diagnosis. The authors describe a 61 year old man presenting with annular pancreas. A discussion of the typical presentation, prevalence, and surgical management is included. Purpose (a): In modern medicine, annular pancreas remains a rare congenital abnormality yet it is the second most common kind of pancreatic fusion abnormality after pancreas divisum.1 Annular pancreas is more often seen in the pediatric patient population so it is an uncommon find among adults. In the adult population, it usually presents between 20 and 50 years of age. This abnormality results from failure of the ventral pancreatic bud during normal migration during development. Ectopic pancreatic tissue persists, encircling the duodenum.2 Most commonly the second portion of the duodenum is involved in 74% of cases.1 Hence, this can lead to duodenal obstruction. Only 737 reported cases of annular pancreas are found in English scientific literature.1,2 Imaging modalities often have their limitations in the management of this anomaly as well. In addition, treatment is still not entirely straightforward in adults as this condition can mimic many other conditions that have to be ruled out. Treatment is always surgical once the diagnosis of symptomatic annular pancreas is clearly formulated.1 Surgical options include duodenoduodenostomy, gastrojejunostomy with vagotomy, duodenojejunostomy, or very rarely, pancreatic resection.1,2,3 In the following case, the patient underwent a duodenoduodenostomy, which is the treatment of choice. Methods (b): A 61 year-old Caucasian male presented to an outside facility with a one month history of intermittent, postprandial right upper quadrant pain and a knot-like sensation and fullness after meals. He arrived at the facility after one week of increasing pain precipitated after eating a Reuben sandwich. Though the patient did not have a history of dyspepsia, he described a burning pain much like indigestion that had become severe and was now located in the epigastric region. He reported no nausea, vomiting, or change in bowel movements. However, he did state an increase in eructation. Laying supine aggravated the pain while belching alleviated the pain. He had no fever, chills, shortness of breath, cough or chest pain. Nevertheless, his initial lab work indicated a white count of 12,600 with left shift. He also had no jaundice and labs indicated normal liver function tests (LFTs). His past medical history included hypertension, high cholesterol, and benign prostatic hyperplasia. Past surgical history included three orthopedic surgeries. At the outside facility he received computerized tomography (CT) of the abdomen and pelvis with IV and p.o. contrast. CT revealed an annular pancreas with no free air or free fluid in the pancreas along with a moderately dilated stomach, and nondilated fluid-filled small bowel loops in the right lower quadrant potentially suggesting gastroenteritis. After transfer to our facility, he was seen in clinic and admitted. His symptoms had abated by this point and his white blood count had fallen to 9,400. Next, he was seen by a gastroenterologist. An upper gastrointestinal series unmistakably revealed moderate to severe stricture of the second part of the duodenum. Repeat CT again indicated an annular pancreas with no free air or free fluid in the pancreas along with a moderately dilated stomach, nondilated fluid-filled small bowel loops in the right lower quadrant potentially suggesting gastroenteritis along with a normal appendix. Moreover, the gastroenterologist performed an esophagogastroduodenoscopy (EGD) that denoted gastritis in the antrum, food debris in the bulb of the duodenum, and stenosis in the descending portion of the duodenum. The endoscope could not be passed distally. Furthermore, the esophagus and gastroesophageal junction had a normal appearance. Surgery was recommended. The patient’s preoperative diagnoses were annular pancreas and gastric outlet obstruction. He consented to either a duodenoduodenostomy or duodenojejunostomy for bypass of the duodenal obstruction and he understood the risks involved. The patient was taken to the operating room, placed under general anesthesia in the supine postion, and the abdomen was prepped and draped sterilely. An upper midline incision was made, adhesions present in the right upper quadrant were removed, and the gallbladder was noted to be intact. Afterward, the duodenum was kocherized and isolated. An annular pancreas was noted that was causing obstruction. The duodenum was entirely mobilized and a side-to-side duodenoduodenostomy was created. This was done by making a transverse incision in the first portion of the duodenum followed by a longitudinal incision in the distal duodenum. A single layer anastomosis was created in a running fashion. Air leaks were checked for by threading the nasogastric (NG) tube through the anastomosis and insufflating air under water immersion. No bubbling was present. Subsequently, the omentum was placed over the right upper quadrant, an On-Q pain pump was positioned in the preperitoneal area and Seprafilm was applied. Finally, the abdomen was closed. The patient tolerated the procedure well and was discharged on the fifth postoperative day. The patient made a complete recovery and was in good health at his two week follow-up visit. Results (c): Annular pancreas was first described in 1818 by Tieddman and the first surgical intervention was implemented by Vidal in 1905.1,2 Though Vasconcelos and Sadek reported only a sole annular pancreas case among 22,243 autopsies, this incidence may not be accurate since duodenal dissection is not performed customarily during autopsy. Thus, the 1.14% incidence reported by Karasaki et al. may be more correct as it based on institutional CT scans.1 Many theories have been conceived about the possible origins of annular pancreas. In 1910, Baldwin speculated that this abnormality arose from aberrant movement and the failure of atrophy of the ventral pancreatic bud. Lecco theorized that adherence of the ventral pancreas to the duodenum in place of normal migration was responsible.1,2 Verga believed that a narrow duodenum was the primary problem; the pancreas simply attempted to rectify the defect by filling the space around the duodenum.2 Most reported cases are among the pediatric population and demonstrate a female preponderance. In the pediatric population, other congenital abnormalities such as cardiac defects, intestinal atresia, biliary anomalies, tracheoesophageal fistulae, intestinal malrotation and trisomy-21 are also often present with annular pancreas.5 In the adult population, 70% of patients present with abdominal pain while 47% present with nausea and vomiting because of proximal duodenal obstruction.2 Patients may also present with asymptomatic pancreatic hyperenzymemia.3 According to an estimate, only 33% of infants and adults are symptomatic.2 Annular pancreas is a great imitator of other conditions because of its variability in presentation among the adult population. Peptic ulcer disease, acute and chronic pancreatitis, and gastroduodenal tuberculosis (if in endemic areas) have to be ruled out. It is seldom associated with obstructive jaundice or malignancy.1,2 Many options exist for imaging including CT, Magnetic resonance cholangiopancreatography (MRCP), Endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). CT clearly delineates the ventral pancreatic ring encircling the duodenum (a complete ring is not required for diagnosis).4 In fact, 75% of annular pancreas cases have a partial ring around the duodenum.3 MRCP can show a pancreatic duct surrounding the duodenum but a dilated pancreatic ductal system is mandatory.2 ERCP can also be used to rule out other conditions but it is an invasive procedure that can be impeded by stenosis of the duodenum. ERCP can also cause or worsen acute pancreatitis.2,3 EUS can assess not only the pancreatic duct but also the parenchyma.3 Surgery is indicated in all symptomatic cases.1,2 Duodenoduodenostomy is preferred because it produces the least amount of blind loop segment.1 Gastrojejunostomy can be performed if vagotomy is also done; vagotomy prevents the risk of peptic ulcer and anastomotic ulcer by decreasing gastric acid secretion.1,2 Pancreatic resection is frequently avoided because of the risk of pancreatic or duodenal fistula, pancreatitis, and pancreatic insufficiency. Even minor pancreatic leaks after resection can result in serious inflammation and fibrosis, ultimately leading to luminal compromise of nearby structures. Resection is only employed if malignancy cannot be excluded.1 Conclusions (d): In modern medicine, physicians are frequently instructed to think of horses, not zebras when they hear hoofbeats. Despite the fact that annular pancreas is extremely rare in an adult patient population, annular pancreas deserves to be a part of a clinician’s differential when a patient presents with abdominal pain, nausea and vomiting, and other signs of gastric outlet or duodenal obstruction. Certainly, other probable conditions like peptic ulcer disease and acute and chronic pancreatitis have to excluded. CT is the imaging modality that is most frequently utilized to derive a diagnosis of annular pancreas but modalities like EUS, MRCP, and ERCP are also viable options. In symptomatic patients, treatment remains strictly surgical. Duodenoduodenostomy or duodenojejunostomy remain as the preferred bypass techniques to relieve obstruction. Gastrojejunostomy with vagotomy is another potential surgical option.
CERVICAL PREGNANCY: A LIFE-THREATENING GESTATION
(2014-03) Ebrahim, Marianne; Golikeri, Rita; Hinkle, Kollier; Marshall, Hayley; Patel, Bimal
When a pregnancy implants someplace other than inside the uterus it is referred to as an ectopic pregnancy. In rare instances a fertilized ovum may implant in the cervical canal and is called a cervical ectopic pregnancy (CEP). CEP occurs in 1:9000 pregnancies. CEP can be organ and life threatening and have significant effects on future fertility. We describe a case that was managed with methotrexate and uterine artery embolization (UAE) instead of surgery. This allowed for preservation of her uterus and potential future childbearing. Purpose (a): The purpose of this case report is to share our experience with a less common but possibly fertility-sparing therapy. Our case is of a 35 year-old G3P2 woman with a CEP who presented with profuse vaginal bleeding. Since the patient desired future fertility, she was treated with an ultrasound-guided UAE instead of a hysterectomy, followed by use of methotrexate (MTX) and leucovorin. Methods (b): The patient's chart was reviewed to gather information regarding her history and hospital management course. This 35 year-old G3P2 female presented with a two week history of active vaginal bleeding, symptomatic anemia, and a positive home pregnancy test. Transvaginal ultrasound (TVUS) revealed an 8-week pregnancy within the endocervical canal, consistent with a CEP. Definitive treatment for a CEP is hysterectomy, but as the patient desired future fertility, a less invasive option of UAE followed by MTX and leucovorin was chosen. She received three doses of MTX and leucovorin, and her serum b-hCG was followed to zero. Results (c): The patient underwent successful UAE. CEP was not seen on TVUS five days after treatment began. She showed appropriate decreases in serum b-hCG and transitioned to outpatient care. With successful non-invasive elimination of the CEP, this patient avoided a potentially fatal hemorrhage and possibly retained fertility. The patient was still awaiting spontaneous menses one month after the procedure. While a definitive cause is unknown, as in our patient, several theories exist for its cause. Risk factors include cervico-uterine instrumentation, in vitro fertilization, and history of pelvic inflammatory disease. Historically, treatment of CEP was with hysterectomy, but other approaches have been used recently in order to avoid infertility and surgical morbidity. Conclusions (d): It is important to recognize the diagnosis of CEP, as it can be mistaken for other conditions, such as a missed abortion proximal to the cervix. The use of UAE is an emerging trend in the management of CEP due to its high success rate and preservation of future fertility. Literature on the subject is limited to observational studies and anecdotal evidence. Complications of UAE include permanent amenorrhea, claudication and other issues if another artery is embolized. Reporting of this and similar cases may contribute to improved methods of managing CEP.
ANTI-NMDA RECEPTOR ANTIBODY ENCEPHALITIS: A CASE STUDY
(2014-03) Mantilla, Emmanuel C. Jr.; Smith-Barbaro, Peggy; Brown, Allene; Khan, Saud
We present the case of a 25 year old Hispanic female, who presented to the ED with status epilepticus. She has had frequent hospital admissions since her seizures started six months ago, described as tonic clonic jerking. Her episodes have been associated with receptive and expressive aphasia, changes in personality, aggression, and flat affect. Work up revealed a normal MRI, intermittent slowing on EEG (Fig. 1), and lymphocytic pleocytosis with 4+ oligoclonal bands. NMDA receptor antibody encephalitis was highly suspected. Intravenous Solumedrol was given, with minimal improvement. Serology sent came back positive for NMDA receptor antibodies. Anti-N-methyl-D-asparate receptor (NMDAR) antibody encephalitis is a paraneoplastic syndrome affecting younger women, characterized by psychiatric symptoms, autonomic instability, neurologic abnormalities, and tonic-clonic type of seizures. CSF usually reveals lymphocytic pleocytosis, and MRI findings are non-specific. Diagnosis is confirmed with serology. 1 A large percentage of patients diagnosed also present with a detectable tumor, the most common of which is ovarian teratoma. 2 Anti-NMDA receptor antibody encephalitis is very responsive to treatment. The first line of management includes steroids, immunoglobulins, and plasma exchange. Rituximab and cyclophosphamide have shown to improve outcome in refractory cases. 3 Purpose (a): To describe a patient with anti-NMDA Receptor Antibody Encephalitis, discuss the clinical features based on this case study, and explore the management options for this condition. Methods (b): This is a case study on a 25 year old Hispanic female with no history of childhood seizures, who presented to the ED with status epilepticus. She has had frequent hospital admissions since her seizures started six months ago, described as tonic clonic jerking. Her episodes have been associated with intermittent receptive and expressive aphasia, changes in personality, aggression, and flat affect. During these admissions, all of her work-up, including MRI, CT scan, and CSF analysis have been negative for causing seizures. Her EEG has showed seizure focus and slowing of waves during these episodes. She has been followed by an outpatient neurologist, who has placed her on several anti-seizure medications, including Depakote, Tegretol, and Zonegran. On her latest admission, she presented to the ED with partial complex status epilepticus, exhibited generalized tonic-clonic movements, with associated tongue biting and urinary incontinence. Two days prior, she had bouts of nausea and vomiting. She was given Ativan and Cerebryx, which eventually resolved seizure activity. Further work up later revealed a normal MRI, intermittent slowing on repeat EEG, and lymphocytic pleocytosis with 4+ oligoclonal bands. Results (c): NMDA receptor antibody encephalitis was highly suspected. She was given Intravenous Solumedrol, minimal improvement was noted. Abdominal and pelvic CT were negative any neoplastic disease, including ovarian teratoma. Serology sent later came back positive for NMDA receptor antibodies. Conclusions (d): Anti-NMDA receptor antibody diagnosis should be high suspected in a young person presenting with seizures, psychiatric symptoms, speech disturbance, orofacial dyskinesias, and autonomic instability. Work-up should include serum and CSF titers for antibodies to NMDA receptors (NR1/NR2), as well as an extensive screen for any neoplasitic diseases, most especially ovarian teratomas in females.
WHERE LESIONS COLLIDE: THE SELLA TURCICA
(2014-03) Windham, Ashley K.; Dawley, Troy; Chow, Tom
Purpose (a): Collision tumors are neoplasms involving two types of histology in one mass. Collision tumors of the sella turcica are a rare species of brain tumors and the information is sparse. Most commonly, the tumors are comprised of more than one type of adenoma. There has been no published case of a collision tumor involving a neuroendocrine and adenomatous histology, which we present a case here. The purpose of this case report was to review the differential diagnosis of sellar and parasellar masses. Also, we aimed to hypothesize about the etiology of collision tumors in the sella and present this unique case of a collision tumor. Methods (b): A case report of one pituitary microadenoma of a 72 year old Caucasian female who presented with eye pain and headaches. The tumor was removed transsphenoidally and histopathologically categorized. Results (c): The tumor was histologically diagnosed as a collision tumor involving a neuroendocrine tumor with a pituitary adenomatous component. Immunohistochemistry revealed a strongly positive synaptophysin stain with a weakly positive Ki-67 in the spindle cell regions. Adrenocorticotropic hormone, prolactin, growth hormone, luteinizing hormone, follicle-stimulating hormone, glial fibrillary acidic protein, CAM 5.2 and p53 stains were are grossly negative. Conclusions (d): Collision tumors are a rare phenomenon involving the sella turcica. A review of literature reveals very few collision tumors as well as no publication with a neuroendocrine tumor colliding with a pituitary adenoma. This case adds to the already extensive differential diagnosis for sella turcica masses.
REMOVAL OF A MESOAPPENDIX DURING A ROUTINE APPENDECTOMY IN A CASE OF APPENDICITIS
(2014-03) Bahrami, Arash; Ho, Eric J.; Cheung, Ryan J.; Buczek, Ronald; Smith-Barbaro, Peggy
Appendectomies are one of the most common emergent surgical procedures performed around the world. Although typically a straight forward operation, it is still important to verify the pathology of the resected tissue and to ensure patient health improvement to confirm a successful surgery. This case report describes a patient who presented to the emergency department with an acute onset of fever and lower abdominal pain, and subsequently underwent two exploratory appendectomies. The surgery team removed the supposed “appendix” along with fecalith, which turned out to be mesoappendix on the pathology report. The patient’s symptoms improved initially, but he developed another fever, at which time he underwent a second exploratory appendectomy. This time, the appendix was removed successfully, which was confirmed by the pathology report, and the patient underwent a full recovery without further complications. Purpose (a): The purpose of this case report was to discuss the importance of pseudoduplication and duplication of the appendix while performing an appendectomy. Methods (b): The patient was a 58-year-old Caucasian male, with an unremarkable past medical and surgical history, who presented to the emergency department with an abrupt onset of fever and chills in the morning and mild burning periumbilical abdominal pain, which was temporarily relieved by an antacid tablet. Physical examination was within normal limits, and the patient was admitted to the hospital and placed on Vancomycin and Zosyn. Overnight, the patient developed right lower quadrant abdominal pain. Blood work confirmed an elevated WBC count and CT scan showed findings that were consistent with acute appendicitis. After consents were signed, the patient was taken to the operating room the following morning for a laparoscopic appendectomy. Results (c): The patient underwent an unsuccessful laparoscopic surgery since the base of the appendix could not be visualized. As a result, the procedure was converted to an open appendectomy; the appendix was resected and the sample was sent to pathology. Following the surgery, the patient was placed on Zosyn and Flagyl for 24 hours. The patient was progressing well until he developed a fever of 102° F, at which time the pathology report came back and revealed the removed tissue sample was an “abundant acute inflammation involving serosal surface of adipose tissue and sheet like portion of mesoappendix covered with fibromembranous tissue.” The patient consented to a re-exploration of his abdomen, and the surgeons took the patient back to the operating room, where they identified the inflamed appendix and the appendiceal artery. The specimen was removed and was confirmed by pathology as the appendix. The patient had an uneventful post-operative course with a full recovery and was subsequently discharged home. Conclusions (d): Surgeons need to be aware of pseudoduplication and the duplication of the appendix while performing an appendectomy. Although rare, it can become an unexpected complication and increase the morbidity and mortality in the patients. Therefore, it is recommended for physicians to perform a thorough assessment of the patient’s anatomy during the surgical procedure to reduce and eliminate future complications from duplicate or even triplicate appendices.
BILATERAL APPEARANCE OF THE ABDUCTOR DIGITI MINIMI ACCESSORIUS ORIGINATING FROM THE PALMARIS LONGUS MUSCLES: A CASE STUDY
(2014-03) Balcar, Brittany L.; Crocker, Kayla M.; Fang, Hesper; Liu, Howe
Background. The palmaris longus (PL) is a slender muscle which arises from the common flexor tendon on the medial epicondyle of the humerus, runs along the medial side of flexor carpi radialis, and attaches distally to the palmar aponeurosis. It consists of a short muscle belly proximally and a long tendon distally. Functionally, the PL aids the flexor carpi radialis and flexor carpi ulnaris in wrist flexion. The PL is known to be one of the most variable muscles in the body. Previous reports include cases of both unilateral and bilateral: reversal, double appearance, absence, variable size and position of muscle belly, and hypertrophy. Therefore, the clinician must consider the possibility of abnormal PL when conducting differential diagnosis of distal forearm pathology. Purpose (a): The purposes of this case study were to 1) examine the bilateral variations of the PL in a male cadaver at the University of North Texas Health Science Center (UNTHSC), and 2) determine the potential clinical significance of this variation. Methods (b): During a routine dissection of a 59-year old male cadaver in year 2005, an unusual PL muscle was discovered in both right and left upper extremities. The dissection was performed by physical therapy students at UNTHSC. Results (c): The PL muscle originated at the medial epicondyle of the humerus and split into two connected tendon bundles at the upper one-fourth of the anterior forearm. The tendon bundles then passed down into the lower one-third of the anterior forearm and separated completely, forming a proper PL tendon and a variant muscle mass –the belly of the ADMA muscle. The PL tendon passed through, as normally seen, to fuse with the palmar aponeurosis, while the ADMA continued distally and medially, passing underneath the palmaris brevis muscle but immediately anterior to Guyon's canal. The ADMA joined, but did not fuse with, the intrinsic abductor digiti minimi muscle, to insert into the medial base of the proximal phalanx of the little finger. Conclusions (d): This case presents a novel bilateral appearance of the ADMA originating from the PL. This is relevant to surgeons who perform operations on or using the PL tendon, and to clinicians diagnosing and treating afflictions of the distal forearm, especially with regard to issues concerning Guyon's canal.
SEVERE HYPONATREMIA IN AN INFANT WITH PSEUDOHYPOALDOSTERONISM
(2014-03) Douglass, Matthew; Wilson, Don; Fiocchi, Casey; Dallas, John; Radack, Jill
Purpose (a): The purpose of this project is to present an interesting case of severe hyponatremia in an infant with pseudohypoaldosteronism and present information about the disease Pseudohypoaldosteronism including: definition, characteristics, etiology, presentation, management, and prognosis. Methods (b): Materials consist of a single patient’s records and methods consist of review of those records and a thorough review of published literature on Pseudohypoaldosteronism as available on Pubmed. Results (c): The patient was found to have a previously unidentified mutation in the genes known to be associated with autosomal dominant form of Pseudohypoaldosteronism and has required supplemental sodium of 11 mEq/kg/day in addition to a low potassium diet and potassium binding agents to make up for renal losses of sodium and hyperkalemia due to his disease. Conclusions (d): This patient has a novel gene mutation causing his disease and has required treatment of persistent electrolyte abnormalities by sodium supplements and potassium binding agents.
DIAGNOSING MULTIPLE SCLEROSIS IN A 9 YEAR OLD BOY – CASE STUDY
(2014-03) Shaygan, Lida; Bowman, W. Paul; Wang, Ching
Diagnosis of multiple sclerosis (MS) in children, especially those less than 11 years old, can be a challenge for physicians. The disease can be easily not considered in children or misdiagnosed. Most pediatric MS patients who are less than 11 years present with clinical features that are difficult to discern from acute disseminated encephalomyelitis (ADEM). Purpose (a): This case study aims to highlight the clinical features and imaging results of multiple sclerosis seen in a 9 year old boy and to distinguish these from ADEM, which presents with similar clinical features and is usually first diagnosed in pediatric patients. Methods (b): Information and records were obtained on a 9 year old boy diagnosed with MS who presented initially with a history of relapsing and remitting episodes of somnolence, hemiparesis, blurred vision and dizziness at Driscoll Children's Hospital in Corpus Christi. Results (c): Clinical features and MRI data after 3 months confirmed diagnosis of MS, and he was placed on the long-term immuno- modulatory therapy, Copaxon. Conclusions (d): Children, especially those with ADEM, should be monitored closely for other transient neurological symptoms, such as blurry vision or episodes of dizziness that resolve on their own. These symptoms commonly present in kids who may develop multiple sclerosis.

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