United States

Abstract
Background: Arnold-Chiari malformation presents unique considerations during pregnancy and delivery due to its neurological implications. While cesarean delivery is often considered for safety, limited data exist regarding maternal outcomes across different racial groups and delivery methods in Chiari patients.

Objective: To assess maternal and obstetric outcomes by delivery method (vaginal vs. cesarean) in Black and White pregnant patients diagnosed with Chiari malformation.

Methods: A retrospective cohort study was conducted using TriNetX, an electronic health record-based research network. Separate cohorts of Black and White pregnant patients with Chiari malformation (ICD-10 Q07.0) were constructed. Patients were stratified by delivery method using CPT codes for vaginal and cesarean delivery. Maternal outcomes were compared using ICD-10 codes for gestational hypertension (O13), preeclampsia (O14), eclampsia (O15), perineal laceration (O70), and other labor-related complications (O60–O77).

Results: Among White patients (n=1,522), vaginal delivery was associated with a significantly lower risk of pre-eclampsia compared to cesarean delivery (4.0% vs 7.1%, p=0.02). This association was not statistically significant in Black patients (4.1% vs 5.7%, p=0.246). Although eclampsia was higher in vaginal deliveries for both races, it did not reach statistical significance. Perineal lacerations were significantly more common in vaginal deliveries among Black patients (12.7% vs 2.0%, p&lt;0.001). No significant racial differences were found in rates of headache, fetal heart abnormalities, or hypertensive disorders.
Conclusion: 
White patients with AC malformation had significantly increased risk of pre-eclampsia following cesarean delivery, suggesting a potential benefit of vaginal delivery when feasible. Racial differences in maternal outcomes were limited but suggest potential disparities in delivery-related complications such as perineal trauma. Further studies adjusting for socioeconomic and clinical covariates are warranted.
Key words: Maternal outcomes; Chiari malformation; gestational hypertension, preeclampsia; eclampsia;
Declarations of interest: none
Funding: none


AMA Research Challenge 2025 

Beyond Assumptions: Racial and Delivery Method Outcomes in Pregnant Patients With Chiari Malformation

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Abstract
Background: Arnold-Chiari malformation presents unique considerations during pregnancy and delivery due to its neurological implications. While cesarean delivery is often considered for safety, limited data exist regarding maternal outcomes across different racial groups and delivery methods in Chiari patients.

Objective: To assess maternal and obstetric outcomes by delivery method (vaginal vs. cesarean) in Black and White pregnant patients diagnosed with Chiari malformation.

Methods: A retrospective cohort study was conducted using TriNetX, an electronic health record-based research network. Separate cohorts of Black and White pregnant patients with Chiari malformation (ICD-10 Q07.0) were constructed. Patients were stratified by delivery method using CPT codes for vaginal and cesarean delivery. Maternal outcomes were compared using ICD-10 codes for gestational hypertension (O13), preeclampsia (O14), eclampsia (O15), perineal laceration (O70), and other labor-related complications (O60–O77).

Results: Among White patients (n=1,522), vaginal delivery was associated with a significantly lower risk of pre-eclampsia compared to cesarean delivery (4.0% vs 7.1%, p=0.02). This association was not statistically significant in Black patients (4.1% vs 5.7%, p=0.246). Although eclampsia was higher in vaginal deliveries for both races, it did not reach statistical significance. Perineal lacerations were significantly more common in vaginal deliveries among Black patients (12.7% vs 2.0%, p<0.001). No significant racial differences were found in rates of headache, fetal heart abnormalities, or hypertensive disorders.
Conclusion: 
White patients with AC malformation had significantly increased risk of pre-eclampsia following cesarean delivery, suggesting a potential benefit of vaginal delivery when feasible. Racial differences in maternal outcomes were limited but suggest potential disparities in delivery-related complications such as perineal trauma. Further studies adjusting for socioeconomic and clinical covariates are warranted.
Key words: Maternal outcomes; Chiari malformation; gestational hypertension, preeclampsia; eclampsia;
Declarations of interest: none
Funding: none


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Introduction: The treatment of laryngeal cancer often results in alterations of speech and swallowing, which may contribute to the development of depression in this patient population and subsequently affect treatment outcomes and survivorship. This study aims to determine the prevalence of depression in patients with laryngeal cancer and identify contributing risk factors. 

Methods: Patients with laryngeal cancer were identified using ICD-10 codes within the TriNetX Research Network. Patients were stratified by treatment type (surgical versus non-surgical), age, socioeconomic (SES) risk factors, and post-treatment side effects. The effect of these factors on the development of depression was analyzed while controlling for cancer stage. 

Results: 93,018 patients with laryngeal cancer were identified. These patients had a significantly higher risk of depression compared to the overall head and neck cancer population (RR=1.15, 95% CI: [1.12,1.18]). Patients under 70 were more likely to develop depression than those over 70 (RR=1.27, 95% CI: [1.22,1.33]). SES risk factors were associated with over double the risk of depression (RR=2.67, 95% CI: [2.42,2.97]). Surgical treatment conferred a higher risk than non-surgical treatment modalities (RR=1.54, 95% CI: [1.41,1.68]). Patients who experienced long-term complications such as dysphagia, xerostomia, or malnutrition had a 7.62% increased risk of depression (p&lt;0.01). 

Conclusions: Patients with laryngeal cancer face a uniquely high risk of developing post-treatment depression. Future studies evaluating optimal screening protocols and supportive care strategies may help improve mental health care in this population.

Depression Among Patients With Laryngeal Cancer: A Retrospective TriNetX Study

Background
Developing novel, safe treatments for adolescent depression is imperative, as rates of depression are rising and conventional pharmacotherapies are often limited by modest efficacy and considerable side effects. Stanford Accelerated Intelligent Neuromodulation Therapy (SAINTTM), an optimized precision-targeted form of transcranial magnetic stimulation, is FDA-cleared for treatment-resistant depression in adults but remains understudied in adolescents. This pilot study investigates if SAINT, a rapid-acting noninvasive intervention with minimal side effects, can address this urgent need. We evaluate the safety, tolerability, and efficacy of SAINT in treatment-naïve adolescents experiencing their first episode of depression who remain antidepressant-free throughout treatment. By studying this demographic, we provide compelling evidence for SAINT as a first-line treatment. SAINT, however, requires a substantial time commitment—5 consecutive 10-hour days. This study introduces Truncated SAINT: a half-dose protocol of five consecutive 5-hour days supported by SAINT trials showing depression remission in highly treatment-resistant subjects after an average of 26 sessions. We hypothesize Truncated SAINT will yield equivalent antidepressant effects to Standard SAINT, with greater acceptability, preference, convenience, and overall satisfaction.

Methods
Two study arms will recruit 20 participants each to receive Standard or Truncated SAINT in a single-blind open-label design. The primary outcome is change in Children’s Depression Rating Scale-Revised (CDRS-R) scores one month post-treatment. Pre- and post-treatment interviews with adolescents and their parents provide measures of acceptability, preference, convenience, and satisfaction. All participants receive a brain resting-state functional magnetic resonance image (rs-fMRI) before treatment to identify the personalized treatment target. Two additional brain rs-fMRIs are obtained at the immediate and one-month follow-up visits to investigate changes in functional connectivity from baseline. Participants remain antidepressant-free for one month post-treatment, after which they resume standard psychiatric care. Participants are followed for 6 months to assess treatment durability.

Results
As of this writing, four participants have completed treatment for the study with three completing the primary outcome measure CDRS-R at the one-month follow-up. No adverse events have been reported. CDRS-R decreased from 60 to 22, 36 to 17, and 49 to 21 from baseline to one-month post-treatment in these subjects. 

Conclusion
Preliminary results suggest that both Standard and Truncated SAINT are safe and efficacious with no adverse events reported. Both participants who completed their one-month follow-up achieved depression remission. We expect SAINT to continue to demonstrate safety and efficacy and ultimately be considered as a first-line treatment for adolescent depression.


Investigating a Truncated Version of SAINT in Treatment-Naive Adolescents with Depression: An Open-Label Acceptability Trial.

Background
Cardiac myxomas are rare, benign tumors and the most common primary cardiac neoplasms. They are typically found in the left atrium and may present with nonspecific symptoms related to obstruction, embolization, or systemic effects. These tumors can be life-threatening if not detected and treated promptly. Because of their subtle and varied presentation, they can be overlooked until symptoms become severe. Cardiac imaging, such as transthoracic or transesophageal echocardiogram (TTE/TEE) is essential to accurate diagnosis. While traditional management involves open thoracotomy, video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative in select cases. Close follow-up with cardiology is important for management of supraventricular arrythmias that may occur after surgery. 

Case Presentation
A 49-year-old woman with no significant past medical history began experiencing dizziness, fatigue, chest discomfort, and near-syncopal episodes over a two-month period, worse with her typical exercise and running patterns. Initial neurologic evaluation, including brain MRI, showed a small colloid cyst and nonspecific left parietal findings but no clear explanation for her symptoms. An initial cardiac evaluation, which did not include imaging, was unremarkable and reassurance was given. After persistent symptoms, her primary care provider ordered a TTE, which revealed a large, mobile mass measuring 6.3 x 3.6 cm nearly filling the left atrium and prolapsing into the left ventricle, suspicious for a myxoma. She was urgently referred and underwent coronary angiography, which showed normal vessels and incidental blood flow to the mass. The patient quickly proceeded to surgical resection of the mass via thoracotomy. Pathology confirmed a left atrial myxoma measuring 6.2 x 5.5 x 2.5 cm. Postoperatively, she developed symptomatic atrial flutter with rates >200 bpm, thought to have stemmed from the right atriotomy during surgery. It was initially managed with TEE-guided cardioversion and ultimately resolved with catheter ablation. She has since returned to sinus rhythm and normal activity.
Discussion
This case highlights how cardiac myxomas can present with vague, nonspecific symptoms and mimic neurologic conditions, leading to delays in diagnosis. In this patient, echocardiography was critical in identifying the underlying cause of her symptoms. Prompt surgical resection prevented potential complications such as embolism or sudden cardiac death. The patient’s postoperative atrial arrhythmias underscore the importance of ongoing cardiac monitoring and follow-up. Clinicians should consider cardiac etiologies in patients with unexplained presyncope or exertional symptoms, especially when neurologic workup is inconclusive. Early detection and multidisciplinary care can lead to excellent outcomes in cases like this.


Unexplained Presyncope Unveils a Cardiac Myxoma: A Case of Delayed Diagnosis

Budd-Chiari Syndrome (BCS) is a rare condition characterized by hepatic venous outflow tract obstruction not caused by cardiac disease, pericardial disease, or sinusoidal obstruction syndrome. We present a case of BCS initially mistaken for metastatic liver cancer, highlighting the diagnostic challenge posed by its variable radiologic appearance.
A 36-year-old woman with a past medical history of irritable bowel syndrome (IBS) presented to the emergency department with abdominal pain and distension, nausea, bilious vomiting, and bilateral lower extremity edema. She had been diagnosed with IBS by her primary care provider after months of abdominal discomfort and diarrhea. She denied alcohol, tobacco, or illicit drug use, and her only medication was an oral contraceptive pill. On presentation, she was hemodynamically stable. Laboratory studies were notable for WBC 12.09 × 10⁹/L, total bilirubin 1.9 mg/dL, and alkaline phosphatase 172 U/L; AST and ALT were within normal limits. A CT scan of the abdomen and pelvis showed hepatic parenchymal heterogeneity with nodular, enhancing foci and moderate ascites. A viral hepatitis panel was negative, and CA-125 was elevated at 237 U/mL. MRI revealed an abnormal, heterogeneous liver with morphologic distortion, and compression, but no occlusion, of the hepatic veins. Persistent ascites and omental abnormalities raised concern for peritoneal carcinomatosis. Differential considerations included multifocal hepatic adenomas, focal nodular hyperplasia, or metastatic disease. The caliber of the hepatic veins suggested possible BCS. A percutaneous liver biopsy and peritoneal fluid cytology were obtained. Liver histology showed cirrhotic changes consistent with BCS, without evidence of malignancy. Cytology of ascitic fluid was negative for malignant cells. Additional workup, including alpha-fetoprotein (2.8 ng/mL), autoimmune liver markers, and ceruloplasmin, was unremarkable. The patient was diagnosed with cirrhosis secondary to BCS with features of portal hypertension. She underwent Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement, which reduced the portosystemic gradient from 15 mmHg to 8 mmHg. The patient’s symptoms resolved and she was discharged home on lactulose and apixaban.
This case illustrates how Budd-Chiari syndrome can mimic hepatic malignancy on imaging due to liver heterogeneity and nodularity, vascular distortion, hepatomegaly and ascites. Early recognition and appropriate intervention, such as TIPS, can lead to clinical improvement and avoidance of unnecessary oncologic treatments. Clinicians should maintain a high index of suspicion for BCS in patients presenting with abnormal liver imaging, ascites, and risk factors for venous thrombosis. Timely biopsy and hepatic venous assessment are crucial for accurate diagnosis.

Budd-Chiari Syndrome Masquerading as Hepatocellular Carcinoma

Background: Pediatric dog bites frequently result in imaging evaluations, but geographic disparities influencing these practices are poorly understood. This study investigates whether rurality of patient residence, defined by Rural-Urban Commuting Area (RUCA) codes, impacts imaging use in pediatric dog-bite injuries.

Methods: A cross-sectional analysis was conducted using data from the Pediatric Health Information System (PHIS), which included 13,901 pediatric dog-bite encounters across 45 U.S. children's hospitals from 2021 to 2022. Patient residences were categorized by RUCA codes, ranging from 1 (most urban) to 10 (most rural). Multivariable logistic regression adjusted for demographics, insurance status, hospital disposition, and length of hospital stay, assessing associations between RUCA codes and the likelihood of diagnostic imaging (e.g., radiographs, CT scans, ultrasounds).

Results: Imaging was performed in 21.5% (2,992/13,901) of pediatric dog-bite encounters. Stratification by RUCA classification revealed an increasing trend of imaging use in more rural areas, with the lowest imaging rates in the most urban groups and the highest in the most rural groups. Linear regression analysis revealed a significant positive correlation between RUCA codes and imaging utilization (p = .002), accounting for approximately 72% of the variance in imaging rates (R² = 0.72). Logistic regression further indicated that each one-point RUCA increase was independently associated with higher odds of imaging (β = 0.042 per RUCA point; OR ≈ 1.04 per point; p = .0016). Additionally, longer hospital stays were significantly linked to increased imaging utilization (β = 0.341 per day; OR ≈ 1.41 per day; p < .001).

Conclusion: Pediatric patients from rural areas are significantly more likely to undergo diagnostic imaging for dog-bite injuries than their urban counterparts. This disparity likely reflects differences in available resources, clinical practice patterns, and provider experience rather than differences in injury severity. Although imaging may provide reassurance in rural settings, unnecessary utilization raises concerns about excess radiation exposure and healthcare costs. These findings emphasize the importance of establishing standardized, evidence-based imaging guidelines and enhancing pediatric-specific resources in rural trauma centers to ensure equitable and appropriate pediatric trauma care.

Impact of Rural-Urban Commuting Area Codes on Imaging Utilization in Pediatric Dog-Bite Injuries

Background:
Psoriasis affects 3% of US adults, with treatment costs exceeding $35 billion annually. While biologic therapies have transformed treatment and management, current risk stratification tools fail to predict disease severity, limiting opportunities for early intervention. Traditional single-biomarker approaches show poor predictive accuracy, while evidence-based non-pharmacologic interventions remain underutilized due to inability to identify high-risk patients. Recent machine learning advances in chronic disease phenotyping suggest multi-dimensional clustering may outperform conventional approaches. This study applied unsupervised machine learning to identify clinically meaningful psoriasis phenotypes using routinely available inflammatory, nutritional, and sociodemographic data, aiming to transform risk stratification and enable precision-targeted interventions.

Methods:
We analyzed nationally representative NHANES data (2003-2006, 2011-2014) including 380 adults ≥20 years with complete psoriasis, inflammatory marker, dietary, and sociodemographic data. Psoriasis severity was assessed by self-reported body surface area (BSA) using standardized palm-size references (<1, 1-2, 3-10, >10 palms). Mixed-data clustering utilized Gower's distance metrics and hierarchical clustering algorithms optimized for heterogeneous clinical data. Cluster stability was rigorously validated via bootstrapped Jaccard coefficients (2000 iterations). Survey-weighted analyses accounted for complex sampling design. Multivariable logistic regression models, adjusted for age, sex, race/ethnicity, and alcohol intake, quantified associations between cluster membership and disease severity.

Results:
Two distinct and clinically meaningful phenotypes emerged with high reproducibility (mean Jaccard=0.77). Cluster 2 ("High-Risk Phenotype") demonstrated more severe psoriasis (greater BSA involvement), vitamin deficiencies (D, B2, B12), poor dietary quality, elevated systemic immune-inflammation indices (SII, SIRI residuals), and distinct inflammatory profiles. In adjusted analyses, High-Risk Phenotype membership conferred >2-fold increased odds of severe psoriasis (BSA >10 palms vs. <1 palm: OR=2.24, 95%CI: 1.04-4.80, p=0.038). Binary severity prediction showed even stronger associations (BSA ≥3 vs. <3 palms: OR=2.65, 95%CI: 1.42-4.94, p=0.003), demonstrating superior discriminative ability compared to individual risk factors.


Conclusion:
This machine learning approach identified two clinically distinct psoriasis phenotypes that significantly outperform traditional single-marker prediction models. The High-Risk Phenotype, characterized by systemic inflammation and nutritional deficiencies, enables early identification of patients requiring intensive intervention. These findings support implementation of precision medicine approaches including targeted nutritional supplementation, anti-inflammatory dietary interventions, and earlier biologic therapy consideration. Lastly, these findings underscore potential for health system improvement through EHR-integrated phenotyping using routinely collected laboratory and survey data, potentially reducing healthcare costs while improving patient outcomes through personalized risk-stratified care delivery.

Predictors of High-Risk Psoriasis Phenotypes Identified by Machine Learning in NHANES

Background
Resident-led code status discussions are common in teaching hospitals, yet trainees often lack formal training to navigate these complex conversations effectively. Prior studies show that patients frequently hold unrealistic expectations about resuscitation and are more likely to opt for a do-not-resuscitate (DNR) status when provided with education that supports informed decision-making. Moreover, DNR orders have been associated with the inappropriate withholding of peri-arrest interventions. This study aims to assess internal medicine (IM) residents’ comfort, self-reported practices, and observations related to code status conversations to identify educational gaps and inform targeted training.
Methods
We designed and administered a survey to all residents in our IM program, collecting demographic information, including training level. Residents rated their comfort and knowledge of code status, resuscitation components, and expected outcomes on a 5-point Likert scale. Additional items addressed the frequency, depth, and barriers to discussions; patient-related factors, documentation practices, observations regarding peri-arrest interventions for DNR patients, and conflicting code statuses.
Results
Of 115 residents, 51 responded; 49% were interns. Over 90% expressed comfort discussing code status, but only 72% felt knowledgeable about the expected outcomes of in-hospital cardiac arrest. Discussions occurred most frequently on hospital (74.4%) and ICU admissions (60.5%), but less often during ICU transfers. Major barriers included limited time and patient anxiety. Only 44% reported consistently documenting their conversations. Although over 90% of residents felt familiar with code status components, fewer than half routinely discussed all interventions in the full code bundle. Patient acuity strongly influenced the level of detail of conversations. Of note, 40% of residents reported that ICU transfer, intubation, or vasopressors were ‘always’ or ‘often’ withheld for DNR patients. Additionally, 65% had encountered conflicting code status orders on multiple occasions.
Conclusion
These findings reveal significant knowledge gaps and inconsistencies in how code status conversations and decisions are approached. While residents are having code status conversations more frequently than documented, there is considerable variation based on the stage of care and interventions discussed. Documentation was lacking, and DNR orders were frequently misinterpreted. Moreover, patients’ requests for incompatible interventions underscore persistent misunderstandings. Targeted education is critical to ensure that residents engage in informed, comprehensive, and patient-centered code status conversations. Improving training in this area will enhance decision-making, align care with both clinical standards and patient values, and ultimately improve patient outcomes.

Resident Approaches to Code Status Discussions – Perspectives and Practices

Background: The rise of ChatGPT and similar large language models (LLMs) transformed how medical and dental students accessed information and engaged in learning. This technological shift presented a challenge for educators, necessitating curriculum and policy adjustments. While existing literature has focused on how educators should integrate artificial intelligence tools into curricula, less attention has been placed on the perspectives and actual practices of students themselves. This study aimed to bridge that gap by investigating the usage of and attitudes towards LLMs, centering primarily on OpenAI’s GPT, among medical and dental students at a US allopathic medical school, thereby informing more effective educational strategies.
Methods: A cross-sectional survey was distributed via email to all medical and dental students at a single university, with responses collected through Qualtrics. The survey included multiple-choice, Likert scale, and free-text questions, and remained open for two months. Quantitative data were analyzed descriptively, and inductive thematic analysis was performed on free-text responses.
Results: A total of 160 students completed the survey. Of these, 88% reported using large language models, with 89% preferring OpenAI’s free version of ChatGPT. Overall, 73% of students used these models to supplement their medical/dental education or research. Common uses included quick information retrieval (82%), assistance with school assignments (56%), tutoring (30%), and research assistance/literature reviews (26%). Most students (81%) felt that integrating AI technologies is necessary to keep pace with medical advances but emphasized the need for proper training on the use of artificial intelligence. Thematic analysis revealed a strong student preference for open discussions that promote LLMs as beneficial tools when used appropriately, rather than restrictive bans or negative framings, which some felt could foster irresponsible or covert use. Concerning usage patterns were also identified: 16% of respondents reported not fact-checking LLM-generated information, and most students indicated they do not cite AI tools as sources.
Conclusion: Medical and dental students have integrated ChatGPT and similar large language models into their education. Their widespread adoption, driven by perceived usefulness and efficiency, underscores a critical need for structured educational interventions. The usage patterns identified, including inconsistent fact-checking and lack of citation, highlight significant risks to academic integrity and patient safety as students transition into clinical roles. Students believe educators must develop and implement curricula focused on responsible and effective AI usage, advocating for transparent guidance that embraces AI’s potential rather than discouraging its use. Equipping future clinicians with tools and knowledge will be essential for navigating AI responsibly in both academics and clinical practice.

Navigating the Artificial Intelligence Era: Student Perspectives and Usage Patterns of Large Language Models in Medical and Dental Education

Background: Frailty, a state of reduced physiological reserve, is associated with mortality, morbidity, and poor quality of life in older cancer survivors. Understanding disparities in longitudinal frailty transitions is essential to identify subgroups in need of interventions. We described disparities in one-year frailty phenotype transitions among older cancer survivors by socioeconomic status (SES), hypothesizing that those with less education and lower wealth would experience worse frailty outcomes than their counterparts.
Methods: We conducted a cohort study using rounds 1-9 (2011-19) of the National Health and Aging Trends Study (NHATS), a nationally-representative cohort of older Medicare beneficiaries. We included 1303 older adults (≥65 years) with a self-reported cancer history in round 1. SES was measured by educational attainment (≥high school [HS] diploma vs. <HS) and wealth quartiles (financial assets minus debts). Frailty was assessed using the frailty phenotype, based on five indicators: shrinking, weakness, exhaustion, slowness, and low physical activity. Participants with 0 indicators were classified as robust, those with 1-2 as prefrail, and those with 3-5 as frail. Pooling nine years of data, we estimated one-year transitional probabilities across the frailty phenotype states and death using multistate Markov models stratified by education and wealth. Models adjusted for age, gender, race, and ethnicity and accounted for the NHATS survey design using survey sampling weights.
Results: Median wealth was $95,800 (IQR: $3,750, $339,250) and 75% had a HS diploma. Survivors without a HS diploma were less likely to remain robust (42% vs. 58%), more likely to stay frail (48% vs. 37%), and more likely to transition to poorer frailty states (e.g. robust to prefrail, robust to frail, robust to death, and prefrail to frail) after one year than those with a HS diploma. Survivors in lower wealth quartiles were less likely to remain robust than those in the highest quartile (Q1: 50%, Q2: 52%, Q3: 54%, Q4: 63%) and were more likely to transition to poorer frailty states.
Conclusion: Cancer survivors with lower SES measured by education and wealth experienced poorer frailty transitions than their counterparts. Disentangling the mechanisms behind these disparities is crucial for developing interventions to improve frailty outcomes in this population.

Socioeconomic Disparities in Frailty State Transitions Among Older Cancer Survivors

Background: 
Anaplasma phagocytophilum causes human granulocytic anaplasmosis (HGA). It spreads by tick bites, much like several other tick-borne diseases. Like ehrlichiosis and Lyme disease, anaplasmosis can cause nonspecific flu-like symptoms like fever, headache, myalgia, and leukopenia. However, HGA causes rash in only 6–10% of cases, less than Lyme disease and ehrlichiosis. Vasculitic presentations are exceedingly rare and are more common in equine granulocytic anaplasmosis (EGA) than in HGA. We report HGA in an elderly woman who presented with a petechial rash, proteinuria, and evidence of systemic inflammation, which initially mimicked vasculitis and posed a diagnostic challenge.

Case Presentation:
A 73-year-old woman with hypertension and hyperlipidemia presented with generalized weakness, fatigue, and a diffuse, flattened, circular rash involving the torso and extremities, sparing the palms and soles, for one week, and fever for one day. She reported a tick bite sustained approximately one month prior while gardening. She sustained a fall due to weakness and loss of balance and was brought to the emergency department. On admission, she was febrile (100.8°F), had bilateral lower extremity edema and a diffuse rash. Laboratory evaluation revealed significant thrombocytopenia (platelets 26 K/μL), leukopenia (WBC 3.4 K/μL), hyponatremia (Na 125 mmol/L), elevated AST (110 U/L), and hypoalbuminemia (2.6 g/dL). A urinalysis showed proteinuria (UPCR 1.22). Nephrology was consulted since vasculitis was suspected. Serologic workup showed positive ANA, elevated CRP (14.4 mg/L), RF (49 IU/mL), and elevated IgA (469 mg/dL), but ANCA panels were negative. A punch biopsy was obtained. IV steroids were initiated due to worsening cytopenias, resulting in rapid hematologic improvement. PCR testing confirmed Anaplasma phagocytophilum infection, establishing the diagnosis of HGA. Other tick-borne infections and viral panels were negative, even though EBV IgM and IgG were elevated. The patient’s rash was later suspected to represent a secondary immune-mediated vasculitic response to Anaplasma infection. She improved clinically with doxycycline and adjunctive corticosteroids. Outpatient follow-up was arranged.

Discussion:
This case highlights the diagnostic challenges posed by Anaplasma phagocytophilum infection, particularly when initial findings mimic autoimmune disease. The combination of cytopenias, rash, positive ANA, and proteinuria initially pointed toward systemic vasculitis. However, confirmation of Anaplasma phagocytophilum by PCR and rapid improvement with doxycycline and steroids supported an infectious etiology with a secondary immune-mediated component. To avoid delays in initiation of appropriate treatment, clinicians should maintain high suspicion for tick-borne diseases, even in the presence of autoimmune markers.


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