United States

Background: Group A Streptococcal (GAS) pharyngitis is a common cause of sore throat, but complications like post-streptococcal reactive arthritis (PSRA) are less frequently recognized, particularly in adults with atypical presentations. PSRA typically presents with early-onset, nonmigratory joint pain and limited response to NSAIDs. This case highlights an atypical presentation of PSRA in a young adult, emphasizing the difficulty in diagnosing this condition.

Case Presentation: A 28-year-old female who presented with a sore throat, non-pruritic rash, dysuria, and acute left ankle pain that impaired weight-bearing. Initial rapid strep and mononucleosis tests were negative, and she was prescribed cephalexin. The following day, she returned with worsening joint pain and persistent dysuria; a repeat rapid strep test was positive, and treatment was switched to amoxicillin-clavulanate and topical NSAIDs. Laboratory results revealed elevated inflammatory markers (ESR 51 mm/hr, CRP 36 mg/L), normal ASO titer, low MCH/MCHC, mildly elevated TSH, and negative autoimmune and STI panels. Follow-up bloodwork six weeks later showed resolution of TSH without intervention, new-onset normocytic anemia, and vitamin D insufficiency.

Discussion: This case illustrates an atypical manifestation of PSRA in an adult: afebrile, initially false-negative for GAS, and presenting with monoarticular arthritis and dysuria in the absence of urinary infection. The diagnostic course was further complicated by the normal ASO titer and the evolving lab profile. This report underscores the limitations of current diagnostic tools such as RADTs and ASO in identifying streptococcal complications in non-classic cases. Clinical judgment, repeat testing, and ongoing assessment played a critical role in this patient’s care. This case underscores the limitations of current diagnostic tools and highlights the need for improved diagnostic strategies and follow-up in adult patients with evolving symptoms and initial negative testing.


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Background
Iododerma is a rare cutaneous condition that results from exposure to high levels of iodine, often from imaging contrast, medications like amiodarone, or topical antiseptics. Its nonspecific clinical presentation and histological resemblance to infectious conditions make for a challenging diagnosis.

Case Presentation
A 64-year-old female with multiple chronic conditions, including stage 4 CKD, atrial fibrillation, and HFpEF, was admitted for right lower lobe pneumonia and underwent contrast-enhanced CT imaging. She subsequently developed multiple painful, non-pruritic, purpuric skin lesions, initially appearing on her left arm and later spreading to both upper extremities over 4 days. She was transferred to SLU for rheumatology and dermatology evaluation due to concern for vasculitis. Physical exam revealed purpuric skin lesions, erosions, crusting, and scattered bruising on both forearms and the right posterior arm. Based on this presentation, the initial differentials included several neutrophilic dermatoses, such as Sweet’s syndrome and EED, vasculitis, and deep fungal or atypical mycobacterial infections. The workup included a shave biopsy of lesions from the right posterior upper arm and punch biopsies of lesions from bilateral anterior forearms. Skin biopsies revealed ulceration, necrosis, acanthosis, and dense dermal neutrophilic infiltrates with vacuole-like structures resembling Cryptococcus. However, GMS, tissue Gram, and Fite stains all returned negative. An iodine level was also obtained and returned significantly elevated at 10,074.4 micrograms per liter. In the context of her recent contrast exposure and histological findings, her elevated iodine levels supported the diagnosis of iododerma. The patient was treated with a 30-day course of oral prednisone. There has been no recurrence of the skin lesions after discontinuation of the prednisone.

Discussion
Iododerma can present a diagnostic challenge due to its rarity and histopathological features resembling Cryptococcoid-like structures pointing towards infectious dermatoses. In this case, the clinical picture and histology initially suggested a fungal infection, but negative stains and a history of recent iodine exposure helped guide the diagnostic process towards iododerma. Ultimately, iododerma is a diagnosis of exclusion that requires careful integration of clinical history, histopathological examinations, and other lab testing. Early corticosteroid treatment is the recommended treatment and can lead to favorable outcomes.

Iododerma Mimicking Cryptococcoid Neutrophilic Dermatosis

Background 
Euglycemic diabetic ketoacidosis (DKA) is a unique variant of diabetic ketoacidosis that presents in patients with normal or mildly elevated blood glucose levels, defined as a serum glucose concentration < 250 mg/dL. As euglycemic DKA has an association with newer diabetes treatments, it becomes increasingly important for clinicians to develop an awareness and further recognize its presentation to prevent serious complications and adverse patient outcomes. 
Case Presentation 
A 61-year-old female with type II diabetes and coronary artery disease presented to the emergency department with chest pain, fatigue, and a bilateral upper extremity rash that had worsened over two days. She was afebrile and hemodynamically stable. EKG and troponins were normal. Physical exam was unremarkable except for a bilateral urticarial rash extending from the hands to the forearms. Her initial labs showed a high anion gap metabolic acidosis (bicarbonate 12 mmol/L, anion gap 19 mmol/L) with a glucose of 164 mg/dL. CBC was normal. She was treated with hydroxyzine, methylprednisolone, and famotidine. 
Overnight, her symptoms improved, but her morning labs showed persistent acidosis (anion gap 17 mmol/L, bicarbonate 16 mmol/L) and a glucose of 229 mg/dL. Ketones were 1.49 mmol/L, and venous blood gas revealed pH 7.2, pCO₂ 38 mmHg, HCO₃ 16.7 mmol/L. A diagnosis of euglycemic DKA was made, likely triggered by her use of Dapagliflozin. She was treated with IV insulin, D5W fluids, and discontinuation of her SGLT-2 inhibitor. Her condition stabilized, and she was discharged after three days. 
Discussion 
Despite normal glucose levels, patients with euglycemic DKA exhibit typical DKA features: metabolic acidosis, ketonemia, and an elevated anion gap. The diagnosis is often missed due to the absence of significant hyperglycemia. While traditionally associated with type I diabetes, euglycemic DKA also occurs in type II diabetes, particularly in patients on SGLT-2 inhibitors or those with precipitating factors such as fasting. The mechanism involves insulin deficiency and elevated counterregulatory hormones, leading to increased lipolysis and ketogenesis. Concurrent glycosuria induced by SGLT-2 inhibitors contributes to the misleading euglycemia. 
Symptoms typically include nausea, vomiting, abdominal pain, and general malaise. Treatment consists of IV fluids, insulin, and electrolyte management, with close monitoring of the patient’s clinical and laboratory status. 


Unmasking the Hidden Culprit: A Presentation of Euglycemic DKA

Background:
Chronic subdural hematoma (CSDH) is a common condition in the elderly, often resulting from minor head trauma. While surgical evacuation remains the standard treatment, recurrence rates up to 20% have driven interest in middle meningeal artery (MMA) embolization as a minimally invasive alternative. By targeting the MMA’s role in supplying the neo-membranes associated with CSDH, embolization interrupts the cycle of hemorrhage and inflammation. Although MMA embolization is generally safe, rare complications may occur, including contrast-induced neurotoxicity (CIN), a transient neurological syndrome that arises after iodinated contrast exposure, once other causes have been excluded.

Case Presentation:
An 82-year-old female with a history of hypertension, hyperlipidemia, and ovarian cancer presented with progressive bifrontal headache two months after a fall. Neurological examination was non-focal. Non-contrast head computed tomography (CT) revealed a 1.7 cm left-sided acute-on-chronic subdural hematoma with mass effect. Laboratory evaluation, including coagulation studies, was unremarkable. The patient underwent elective left MMA embolization under conscious sedation.
Approximately one hour post-procedure, she developed sudden-onset expressive aphasia, right-sided weakness, and leftward gaze deviation, with a National Institutes of Health Stroke Scale (NIHSS) score of 16. Emergent non-contrast head CT and CT angiography (CTA) of the head and neck revealed no acute hemorrhage or large vessel occlusion. Brain magnetic resonance imaging (MRI) showed no evidence of acute ischemia. Supportive care with permissive hypertension was initiated. Neurological symptoms resolved completely within 24 hours. Based on the rapid onset and resolution of symptoms, with no imaging abnormalities, CIN was diagnosed. The patient was discharged in stable condition one week later.

Discussion:
MMA embolization is an effective and increasingly utilized treatment for CSDH, particularly in patients with recurrence, high surgical risk, or surgically challenging anatomy. It offers a minimally invasive approach with lower recurrence rates compared to traditional surgery. Although generally safe, CIN is a rare but significant complication of neurointerventional procedures, with reported incidence ranging from 0.15% to 2.5%. It typically presents within hours of contrast exposure with transient neurological symptoms such as encephalopathy, focal deficits, or cortical blindness. Risk factors include advanced age, hypertension, and higher contrast volume. In this case, CIN closely mimicked acute ischemic stroke. Fortunately, it is
typically self-limiting and resolves within 24-72 hours with supportive care. Further research is needed to optimize MMA embolization use and to better understand CIN’s mechanisms and management.

Stroke or Not? Case of Contrast-Induced Neurotoxicity Following Middle Meningeal Artery Embolization

Background
Radiation therapy significantly impacts the success and cosmetic outcome of implant-based breast reconstruction by inducing irreversible alterations in the surrounding tissues. These changes can include fibrosis, radiation dermatitis, tissue damage, and fat necrosis, which collectively impair the reconstructive process. A common complication is the formation of a dense, fibrotic capsule around the implant, known as symptomatic capsular contracture, which can result in breast firmness, asymmetry, and suboptimal aesthetic outcomes. Radiated tissue also demonstrates reduced elasticity, impaired vascularity, and higher susceptibility to wound healing complications such as dehiscence, infection, and implant loss. Reoperation on irradiated pockets is particularly high-risk due to diminished regenerative capacity, increased fibrosis, and poor tissue quality.
Case Presentation
A patient presented with significant post-radiation asymmetry following bilateral implant-based breast reconstruction. The left, radiated breast developed a tight, contracted implant pocket, resulting in a smaller, higher-riding, and firmer breast mound than the contralateral side. Attempts to revise the radiated side were contraindicated due to concerns about implant exposure, infection, and further tissue compromise. To address the asymmetry, reconstructive efforts focused on modifying the non-radiated breast. The original 500 cc implant was replaced with a 480 cc ultra high-profile Mentor MemoryGel implant, which was tightly wrapped in two large perforated acellular dermal matrix (ADM) sheets. These sheets were configured in a bouffant-style to mimic the fibrotic, projected contour of the radiated side. The ADM was anchored high on the chest wall using 2-0 PDS sutures for secure positioning. Additional skin was excised, and the implant capsule was reinforced to prevent bottoming out, ultimately achieving a symmetric result. 
Discussion
This case presentation illustrates the reconstructive challenges posed by radiation therapy, particularly the inability to safely operate on radiated tissue due to compromised vascularity and structural integrity. Instead of correcting the radiated side directly, the surgical team mirrored its shape and projection by modifying the non-radiated breast. The use of ADM provided structural support and allowed precise shaping to achieve symmetry. This strategic approach addressed both aesthetic and functional concerns while minimizing risk. For patients with similar post-radiation asymmetries, individualized planning that avoids direct manipulation of radiated tissue and instead focuses on contralateral adjustments can provide more optimal outcomes.


Achieving Breast Symmetry in Implant Based Reconstruction following Radiation by Manipulating the Non-irradiated Breast


A Rare Case of Iatrogenic Hemothorax Following Thoracentesis Secondary to an Aberrant Posterior Intercostal Artery


Background

Thoracentesis is the initial procedure performed when diagnosing and treating a pleural effusion. The most common complication for this procedure is pneumothorax, with an incidence reported up to 6%, whereas incidence of hemothorax is approximately 1%.


Case Presentation

A 79-year-old female with history of atrial fibrillation, chronic obstructive pulmonary disease, deep vein thrombosis, type 2 diabetes, and early onset myelodysplastic syndrome presented to the emergency department experiencing chest pain and shortness of breath and was admitted to the hospital for atrial fibrillation with rapid ventricular response. Treatment was initiated, including apixaban. Workup revealed a left pleural effusion of unknown origin, so ultrasound-guided diagnostic thoracentesis was successfully performed using a posterolateral approach, and furosemide was initiated.

Within 2 hours, the patient developed extreme dyspnea, becoming hemodynamically unstable, warranting a transfer to intensive care. Repeat chest X-ray revealed a large pleural effusion, so a chest tube was emergently inserted, removing 1 liter of sanguinous fluid.

Given the rapid development of the hemothorax along with the patient’s anticoagulation treatment and recent thoracentesis, a chest computerized tomography angiogram (CTA) was ordered to detect the source of arterial extravasation. It revealed a ruptured aberrant branch of the left 9th intercostal artery coursing inferiorly across the intercostal space and above the 10th rib, which was the cause of the patient’s rapidly developing hemothorax. This artery was treated with coil embolization, which achieved hemostasis and prevented hemothorax recurrence.


Discussion

Hemothorax is a rare complication of thoracentesis when standard technique based on foundational anatomical knowledge is followed. Proper technique involves inserting the needle above the superior rib margin to avoid the neurovascular bundle. Notably, therapeutic anticoagulation is not a contraindication to thoracentesis and has not been shown to increase bleeding risk. The use of imaging guidance reduces the risk of procedural complication; however, anatomical variants and age-related vascular changes, such as increased tortuosity of intercostal vessels, increase the risk. Vessel tortuosity makes medial approaches more hazardous, supporting the recommendation for a posterolateral entry point in the elderly population. 

In the event of suspected vascular injury, as seen in this case, CTA is the diagnostic modality of choice. When active extravasation is identified, coil embolization serves as the preferred intervention to achieve hemostasis and prevent recurrence. This case illustrates a rare and serious complication of thoracentesis secondary to a previously undocumented anatomical variant of the posterior intercostal artery leading to a nearly fatal hemothorax despite appropriate thoracentesis technique.


Safe Technique, Hidden Danger: Post-Thoracentesis Hemothorax from an Intercostal Variant

Background:
The aftermath of whiplash injuries from motor vehicle accidents (MVA) is estimated to cost nearly $4 billion annually in the United States and inflates over sevenfold with litigation costs. In the relationship between whiplash and litigation, prior research cites that no-fault systems generally limit the opportunity for further litigation. However, New York State utilizes a no-fault system that may award plaintiffs further compensation based on a serious injury threshold, for which both injury and treatment are considered. Most MVA do not biomechanically cause disc herniations and are conservatively treated, yet these injuries are frequently litigated. This study examines how treatment of cervical disc herniations claimed in no-fault litigation may impact award compensation, thus evaluating overtreatment as a potential tool to increase compensation.

Methods:
We queried the Thomson Reuters Westlaw database for Jury Verdicts & Settlements in New York that were categorized under “no-fault” and “motor vehicle” and included cervical disc herniation in the claim. 181 of 383 cases from 2005-2011 met the injury criteria and had detailed therapeutic methodology, litigation outcome, and award amount. We categorized cervical disc herniation treatments as surgical or non-surgical. We then separated cases that favored the plaintiff to any degree or were resolved alternatively (Plaintiff Verdict, Settlement, Mediated Settlement, Arbitration, Mixed Verdict) from cases with defendant-oriented outcomes (Defendant Decision and Defendant Verdict). The mean and median true awards (actual value collected by the plaintiff, potentially adjusted by pre-trial high-low agreement) were compared across groups and the Mann-Whitney U Test was used to test significance (p<0.05).

Results:
Of the 181 cases that met our initial query criteria, we included 18 cases describing surgical treatment and 80 cases describing non-surgical treatment that resulted in a plaintiff-oriented outcome. Analysis of included cases demonstrated a significantly greater true award for surgical treatment(s) (n=18, M=$959,257.19, Mdn=$637,500) compared to non-surgical treatment(s) (n=80, M=$195,184.10, Mdn=$74,250, U=141, p<0.001). There was no significant correlation to suggest that either treatment group more often resulted in a defendant or plaintiff-oriented outcome.

Conclusion:
Substantial financial incentives may exist for cervical disc surgical intervention in whiplash compared to more conservative, non-surgical treatment. While neither treatment group resulted in significantly more plaintiff-oriented outcomes, the compensation potential for invasive intervention may still prompt overtreatment. Further work is needed to determine how the medical and legal communities can minimize the economic toll of whiplash while ensuring patients are receiving appropriate care and just compensation.

Impact of Surgical Treatment on Award in NYS No-Fault Accident Claims of Cervical Disc Herniation

Background
Infertility is especially prevalent among female surgeons at all levels of training. Given the high rates of infertility and delayed childbearing among female surgeons, many must utilize assisted reproductive technology (ART) to help them achieve pregnancy. Insurance plans may help offset the financial burden of ART, but coverage has often been limited and inconsistent. This study aims to assess the current status of insurance coverage for ART in orthopaedic surgery residency programs.

Methods
This is a cross-sectional study of 218 orthopaedic surgery residency programs in the United States in 2024. Program websites were searched for resident benefits and insurance coverage for fertility services and dollar coverage for procedures and prescriptions. Program coordinators were identified, and a survey was distributed in addition to phone inquiries about incomplete information and supplemental funding outside of default insurance coverage.

Results
A total of 118 (54.1%) programs had publicly available or available upon request information on insurance coverage of ART. Of those, 106 (90%) had some form of fertility service coverage. Regarding service eligibility, 44 (41.5%) programs required preauthorization, while 15 (14.2%) programs required referrals. IVF and IUI were the most commonly offered ART services, with 75.5% and 71.7% coverage, respectively. The median number of cycles covered was 4 (Q1: 3, Q3: 4), and the median coverage amount was $21,000 (Q1: $15,000; Q3: $30,000). Spousal coverage was offered by 29 (27.4%) programs. Supplemental funding was available at 6 (5.7%) programs.

Conclusion
This study highlights multiple barriers that orthopaedic surgery trainees face to access ART. In addition to limited information availability, there is variation in coverage for adjunct services and minimal supplemental funding from programs. Additional eligibility barriers exist via pre-authorization or referral requirements. Moreover, the median coverage amount may not provide sufficient coverage for some cases. Programs can improve access to fertility treatments and care by promoting transparency and providing supplemental funding.

Assisted Reproductive Technology (ART) Coverage in Orthopaedic Training Programs

Background: The uninsured population of Galveston is estimated at 18.3% of the total 53,000 individuals. Approximately 400 unhoused individuals dwell on the island, comprising .8% of the population. The Luke Society’s mission is to provide care to these patients. Luke’s provides physician consultations, medication, and comprehensive wound care. This study aims to analyze the wounds treated at this free clinic to guide public health interventions in vulnerable populations of Galveston, TX.
Methods: Twenty-six care encounters were documented between September 2024 and February 2025. Data including wound description, location, treatment, and materials provided were recorded. No demographic data or patient identifiers were collected.
Results: 38% of wounds involved the feet and 19% affected the head. 46% were infected and treated with either antibiotics or antifungals. 27% were related to a specific trauma. 73% of patients received materials for wound care and cleaning. 4 of the 26 were post surgical wounds that had been lost to follow up by their surgeon. 
Conclusions: The high prevalence of foot related wounds indicates a lack of sufficient hygiene likely attributed to the high rates of homelessness and a lack of access to consistent showers and clean socks. Head injuries could potentially be prevented with better access to helmets as many of the patients travel on bikes. Underinsured patients have a high rate of being lost to follow up leading to complications and infections following surgeries.
Public Health Implications: Preventative medicine and regular cleaning is highly important in wound care and trauma related injuries. Access to clean socks, helmets, warm water, and basic wound care supplies should be a focus in community health initiatives supporting the underinsured and unhoused populations. With these interventions, chronic wounds could heal faster and potential progression to serious infections.


Wound Care Trends of a Student Run Clinic in the Underinsured and Unhoused Population of Galveston, Texas

Background
The American Diabetes Association recommends annual diabetic retinopathy screening to prevent vision loss, yet national screening rates remain below the Healthy People 2030 target of 70%. Screening rates for diabetic retinopathy at Northwestern Medicine averaged 49.7% in June 2023, indicating care gaps across Chicagoland. 

Methods
Our quality improvement initiative utilized Plan-Do-Study-Act cycles, root cause analysis, and data-driven decision-making. Interventions were applied to both regional Northwestern Medicine primary care clinics and the primary care clinics of the downtown Northwestern academic center. Key interventions included pre-visit questionnaires, practice advisory tools, more frequent health maintenance standards, patient attestations, and automated MyChart messaging. The effectiveness of each intervention was assessed by aligning implementation timing with monthly screening rates. A team of quality improvement professionals evaluated each initiative's impact versus effort to determine scalability.

Results
Screening rates increased from 49.7% to 57% at the downtown campus and from 55% to 59% at regional clinics over a 22-month period.

At the downtown academic center, the implementation of a pre-visit questionnaire (allows patients to report recently completed or upcoming eye exams) in August 2024 increased rates of screening from 50% to 54% within one month. Implementation of patient attestations (allows for self-reporting of completed eye exam status in MyChart) and automated MyChart messaging (messages and scheduling options proactively sent to patients overdue for eye exam) further increased screening rates to 57% over the next 7 months. 

At the regional Northwestern primary care clinics, a standardized practice advisory (notifies staff that a patient is due for an eye exam and prompts them to set up an ophthalmology referral) introduced in June 2023 through March 2025 demonstrated steadily increasing screening rates from 55% to 59%. Additionally, updating the health maintenance frequency (requiring annual diabetic eye exams for all patients with diabetes) in September 2024 demonstrated an almost 1% increase within one month. 

High-impact, low-effort interventions included the pre-visit questionnaire, updated health maintenance frequencies, MyChart messaging, and patient attestations. Resource-intensive but effective measures also included integrating community health workers and a point-of-care camera at the downtown site. Less impactful strategies included distribution of educational materials and a self-scheduling feature.

Conclusion
This initiative highlights effective, scalable strategies for improving diabetic retinopathy screening rates at both academic and regional clinics. These findings may guide similar efforts at other health care systems to address gaps in preventive diabetes care.


Quality Improvement Methods for Improving Diabetic
Retinopathy Screening Rates at a Large Academic Medical
Center and Affiliate Medical Group

Background: Lymphomatoid papulosis (LyP) is a chronic, recurrent, self-healing cutaneous T-cell lymphoproliferative disorder characterized by CD30+ cells. It typically presents with papulonodular eruptions rather than plaques. Mycosis fungoides (MF), a primary cutaneous T-cell lymphoma, is generally persistent and non-migratory. This case highlights an unusual presentation of migratory plaque-like LyP, raising diagnostic challenges with overlap to more serious lymphoproliferations, such as MF.

Case Presentation: A 63-year-old female presented with pruritic plaques and nodules that intermittently appeared and resolved across various body sites. Past episodes were treated as fungal infections, though KOH preps were negative. She had a remote history of shingles but no other relevant systemic symptoms. Two punch biopsies were obtained a week apart, one from the right thigh and the other from the right groin.

Histopathology from both biopsies revealed an atypical intraepidermal T-cell lymphoproliferative disorder with CD30 positivity and a double-negative CD4-/CD8- phenotype by immunohistochemistry. Loss of several T-cell markers (CD2, CD5, CD7) was noted. The dermal component demonstrated a band-like infiltrate of mixed immunophenotype, including CD30 positive lymphoid cells. PAS was negative for fungal elements. T-cell receptor studies were positive for TCR beta clones (261 and 260bp; 294 and 294bp) as well as TCR gamma clones (240 and 239bp). Ancillary FISH for the DUSP22-IRF4 rearrangement is pending. Given the migratory nature of the rash, self-resolution of lesions, and histopathologic work-up with ancillary studies, a diagnosis of an unusual plaque-like variant of lymphomatoid papulosis was made.

Discussion: This case underscores a diagnostic gray zone between LyP and MF. Plaque-like LyP is rare and may be underrecognized due to its clinical resemblance to early MF. The migratory nature of the lesions and spontaneous resolution pointed toward LyP, yet the presence of plaques and immunophenotypic abnormalities added complexity. CD30+ double-negative T-cell populations are uncommon but can occur in LyP, occasionally associated with DUSP22-IRF4 rearrangements. Accurate diagnosis is crucial given the differing prognoses and management strategies between LyP and MF. This case also illustrates the value of serial biopsies and multidisciplinary pathology review in evaluating atypical cutaneous lymphoproliferative disorders.

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