United States

Background
Since 2000 the incidence of syphilis in the United States has increased by over 400%. Classically, secondary syphilis presents as a generalized, non-pruritic, maculopapular rash, often including the palms and soles. However, due to the wide range of mucocutaneous presentations, secondary syphilis is often called ‘The Great Imitator.’ Herein, we report an unusual presentation of secondary syphilis to remind physicians to consider this diagnosis. 

Case Presentation
A 39-year-old female with a history of Hepatitis B presented with a two-month history of numerous tender, crusted, erythematous papules on the face and neck, as well as superficial ulcerations on the tongue, posterior oropharynx, and lower mucosal lip. The lesions first appeared around her nose and mouth after wearing a new cloth mask and then spread more broadly across her face and neck. She had previously been treated with courses of acyclovir and methylprednisolone with no improvement. A seven-day course of sulfamethoxazole-trimethoprim 800mg-160mg resulted in partial healing of some of the lesions. She also endorsed hoarseness and a sore throat but denied additional systemic symptoms, sick contacts, or recent travel. Our differential diagnoses included: sarcoidosis, deep fungal infection, bullous impetigo, Majocchi&#39;s granuloma, cutaneous tuberculosis, cutaneous lymphoma, and lupus.
Punch biopsies revealed superficial and deep dense lymphoplasmacytic infiltrate with spirochetes seen in the epidermis on H&amp;E. The rapid plasma reagin titer was reactive (1:4), and anti-Treponema pallidum IgG was positive, confirming the diagnosis of secondary syphilis. The patient was treated with an intramuscular injection of Penicillin G benzathine resulting in complete resolution of the lesions.

Discussion
The incidence of syphilis infection has been increasing in the United States in recent years. The case described herein demonstrates the importance of including secondary syphilis, an infection that often masquerades as others, in the differential when sexually active patients present with mucocutaneous lesions. Rapid identification is essential to combat this increasingly prevalent infection in the United States, through expeditious treatment and effective contact tracing. 


AMA Research Challenge 2022

The Great Imitator: an unusual presentation of secondary syphilis

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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background
Since 2000 the incidence of syphilis in the United States has increased by over 400%. Classically, secondary syphilis presents as a generalized, non-pruritic, maculopapular rash, often including the palms and soles. However, due to the wide range of mucocutaneous presentations, secondary syphilis is often called ‘The Great Imitator.’ Herein, we report an unusual presentation of secondary syphilis to remind physicians to consider this diagnosis. 

Case Presentation
A 39-year-old female with a history of Hepatitis B presented with a two-month history of numerous tender, crusted, erythematous papules on the face and neck, as well as superficial ulcerations on the tongue, posterior oropharynx, and lower mucosal lip. The lesions first appeared around her nose and mouth after wearing a new cloth mask and then spread more broadly across her face and neck. She had previously been treated with courses of acyclovir and methylprednisolone with no improvement. A seven-day course of sulfamethoxazole-trimethoprim 800mg-160mg resulted in partial healing of some of the lesions. She also endorsed hoarseness and a sore throat but denied additional systemic symptoms, sick contacts, or recent travel. Our differential diagnoses included: sarcoidosis, deep fungal infection, bullous impetigo, Majocchi's granuloma, cutaneous tuberculosis, cutaneous lymphoma, and lupus.
Punch biopsies revealed superficial and deep dense lymphoplasmacytic infiltrate with spirochetes seen in the epidermis on H&E. The rapid plasma reagin titer was reactive (1:4), and anti-Treponema pallidum IgG was positive, confirming the diagnosis of secondary syphilis. The patient was treated with an intramuscular injection of Penicillin G benzathine resulting in complete resolution of the lesions.

Discussion
The incidence of syphilis infection has been increasing in the United States in recent years. The case described herein demonstrates the importance of including secondary syphilis, an infection that often masquerades as others, in the differential when sexually active patients present with mucocutaneous lesions. Rapid identification is essential to combat this increasingly prevalent infection in the United States, through expeditious treatment and effective contact tracing. 


poster

A case of Serotonin syndrome due to the concurrent use of Sertraline, Trazodone, and 
Quetiapine

Open globe ruptures are a common sight-threatening trauma consisting of decreased vision, loss of anterior chamber depth, irregularly shaped pupil, 360-degree subconjunctival hemorrhage, and prolapse of uveal tissue. The delayed presentation further complicates the return of vision with infectivity, and autoimmune pathology, and increases the likelihood of enucleation.

A Man with Traumatic Vision Loss: A Case Report

Abstract Title: Myocarditis preceded by hemolysis secondary to a Loxosceles reclusa bite
Background: Envenomation from the brown recluse spider (Loxosceles reclusa) can cause significant tissue damage or severe systemic illness, primarily potentially fatal hemolysis and renal failure. Few cases demonstrate loxoscelism-induced myocarditis. We present a case of loxoscelism with hemolytic anemia and myocarditis leading to cardiogenic shock and respiratory failure requiring mechanical ventilation.
Case Presentation: A previously healthy 18-year-old man presented to the emergency department with a one-day history of pleuritic chest pain and fever and was discharged with a diagnosis of viral syndrome after an unremarkable workup. He returned to the ED three days with a new morbilliform rash, dark urine, and painful right scapular lesion which reportedly began 5 days earlier. He was initially febrile and hypotensive to 59/49 and was admitted to the intensive care unit. On hospital day two, he had worsening tachycardia and hypotension. Electrocardiogram showed diffuse ST-segment elevation. Troponin peaked at 2.51 ng/mL. Transthoracic echocardiogram showed a maximally depressed ejection fraction of 28%. Respiratory failure ensued requiring intubation and mechanical ventilation. His Coombs positive hemolytic anemia had a hemoglobin nadir of 7.6 g/dL. An ELISA test of the scapular wound (SpiderTek, Rolla, MO) confirmed Loxosceles reclusa venom. By hospital day five, the patient was weaned from inotropes and extubated. He did not receive IV steroids, IVIG, or plasmapheresis. A repeat echocardiogram was normal. The patient was discharged on hospital day nine with a diagnosis of myocarditis.
Discussion: This is the third report of myocarditis associated with loxoscelism, the second case confirmed with a positive test for Loxosceles venom, and the first with an acute course requiring ventilator support. These studies include two cases of cardiac magnetic resonance-confirmed myocarditis. A direct cardiotoxic Loxosceles species venom has been previously demonstrated. Additionally, Interleukin 6, known to be elevated in loxoscelism, is associated with severe myocarditis. The abrupt decrease in cardiac function in an otherwise young, healthy patient, followed by rapid recovery, is consistent with toxin-mediated myocarditis caused by L. reclusa envenomation. Providers should be aware that recluse spider bites can cause life-threatening myocarditis and should tell all patients with recluse bites should seek immediate medical attention for dark urine.

Myocarditis Preceded by Hemolysis Secondary to a Loxosceles Reclusa Bite

This case illustrates a rare presentation of hypothalamic lipoma in a patient who presents with hyperprolactinemia causing galactorrhea in a patient with a Family History of Birt-Hogg-Dubé syndrome. The Birt Hogg Dubé Syndrome (BHD) is a rare autosomal dominant disorder caused by a mutation in the FLCNgene and is only found in approximately 200 families worldwide to date. This condition manifests clinically as fibrofolliculomas, acrochordons, angiofibroma, and pulmonary cysts developing into spontaneous pneumothorax and renal tumors. A few cases of BHD syndrome have recently been reported to have lipomas, angiomyolipomas, and lesions containing abnormal connective tissue. Intracranial lipomas, however, have not been reported. Further genetic analysis in our case may link the possible presentation of intracranial lipomas to BHD syndrome.

A Case of Hypothalamic Lipoma causing Hyperprolactinemia in a Patient with Family History of Birt-Hogg-Dubé syndrome.​

Background
Hemorrhage of the adrenal glands is uncommon and can present with a variety of symptoms. A high index of suspicion based on awareness of risk factors associated with the condition is vital as the condition’s mortality rate is estimated at 15%. 

Case Presentation
CH is a 43-year-old male with past medical history of lupus anticoagulant disorder who presented to his PCP with muscle aches, abdominal pain, confusion, poor appetite and tachycardia. One week prior, he had a deep tissue massage where the therapist walked on his back. He also switched from Coumadin to Xarelto approximately one month ago. Two days prior to presenting to his primary care office, he was discharged from the hospital after being admitted with symptoms of back pain, abdominal pain, constipation and dark urine. A CT during that admission revealed a right-sided adrenal hemorrhage. However, with normalization of his urine color and improvement of his abdominal pain following constipation treatments, he was discharged home. At his PCP’s office, a CMP was ordered that revealed a serum Na level of 120 mg/dl. This result cued his readmission. Further workup revealed elevated ACTH and undetectable serum cortisol levels supporting adrenal insufficiency. He was started on IV normal saline and a hydrocortisone regimen. His symptoms gradually improved, and two days later his serum Na was 132 mg/dl. He was then discharged home with a hydrocortisone taper and a follow-up with endocrinology.

Discussion
Risk factors for adrenal hemorrhage include physical trauma, anticoagulants, hypercoagulable states and severe stressors. Anticoagulants are implicated in one third of patients with adrenal hemorrhage. Additionally, it has been found that there is an increased incidence of hemorrhage within the first weeks of initiating anticoagulants. Imaging of the adrenals, particularly CT of the abdomen, can confirm the diagnosis of adrenal hemorrhage. Serum sodium, ACTH and cortisol levels are also vital to obtain as they provide valuable insight on the presence of adrenal insufficiency. Results supporting the diagnosis of adrenal hemorrhage with adrenal insufficiency should prompt treatment with surgical intervention and/or non-invasive management with glucocorticoids as appropriate. These treatments could be lifesaving.


A Deep Tissue Massage and a Factor Xa Inhibitor: The Recipe for a Life-Threatening Crisis?

Abstract Title:
Flatbush diabetes – ketosis prone atypical diabetes mellitus: A case report

Background:
Flatbush diabetes, also termed as atypical or Ketosis-prone type 2 diabetes mellitus is being increasingly reported. It is characterized by sudden onset ketoacidosis, absence of pancreatic beta cell autoimmunity and dysfunction. Though cases commonly seen amongst African-Americans and Afro-Caribbean individuals, it is also seen in Indian populations. The aetiology is unknown but predisposition to glucose desensitization is suspected.
These patients are typically obese, middle-aged men who has strong family history of type 2 diabetes. Here we report an atypical case of Flatbush diabetes in a young female patient who has no family H/O DM.



Case Presentation:
A 31-year-old female presented to emergency room with complaints of grade IV dyspnea, abdominal distension and 5 episodes of bilious vomiting’s since morning. She has history of recurrent diffuse abdominal pain, vomiting’s, polyuria, polydipsia, weight loss, hair loss for 3 months. Her vitals at presentation are 110/80 mmHg of BP, pulse rate is 122/min and oxygen saturation is 99% on room air.
On examination she is diaphoretic, with severe tachypnea. Capillary blood glucose levels are high (>599). ABG showed PH of 6.99, pCO2 of 7 with no derived values of bicarbonate. urine ketones tested positive with dip stick (3+). She is immediately started on IV fluids and subsequently managed as DKA according to protocols. Her HbA1C is 12%. Her C-peptide levels are with in normal limits. Autoantibodies against GAD, tyrosine phosphatase, insulin are absent. CECT is normal. No family H/O diabetes. She is put on glargine U-100 along with ADA’s and is reviewed after 2 weeks. In these two weeks she didn’t have hypoglycemic attacks and symptoms of DKA, and Urine ketones tested negative. Insulin dose is adjusted and reviewed after 1 month.



Discussion:
This case report sheds light on the atypicality of presentation and summarizes the main diagnostic features of Flatbush diabetes. Absence of autoantibodies to GAD, insulin, tyrosine phosphatase and presence of normal levels of C-peptide rules out type 1 DM. 

This condition may improve after temporary insulin therapy and many patients become insulin-independent eventually. Increased awareness of this atypical form of DM can facilitate early diagnosis and management.



Flatbush diabetes – ketosis prone atypical diabetes mellitus: A case report

Idiopathic Granulomatous Hypophysitis : A Rare Cause of Hypopituitarism

This review analyzes the potential effectiveness of dietary intervention in the management of Polycystic Ovarian Syndrome (PCOS), as well as its associated symptoms and comorbidities. The dietary regimens covered in this review are as follows: the Mediterranean Diet (MD), the Ketogenic Diet (KD), and nutritional therapy utilizing the addition of micronutrients and/or macronutrient distribution manipulation. This review surveys whether effective use of these measures can not only be used as an effective treatment for PCOS but also can assist with its symptoms and comorbidities while limiting drug and surgical regimens.

A literature analysis of English-written, peer-reviewed research through PubMed was conducted to gather evidence on the potential effectiveness of a dietary intervention on PCOS management.

Women who followed a MD were less likely to suffer from PCOS symptoms and lead a healthier lifestyle. This treatment often prevented weight gain, promoted exercise, and decreased the likelihood of development and/or persistence of comorbidities. Additionally, our team gathered significant evidence that the administration of omega-3 fatty acids, folic acid, selenium, vitamin E, catechin, glycyrrhizin, and coenzyme Q10 assists PCOS women, and effectively manages symptoms. 

It can be concluded that the MD allows women to manage and reduce the physical symptoms and comorbidities associated with PCOS most effectively. Firstly, the MD is associated with decreased inflammation, improved hormonal regulation, as well as downregulation of cellular and humoral immunological pathways related to disease activity and progression in PCOS. Although the KD may be beneficial because it reduces carbohydrates leading to improved liver function and insulin sensitivity in PCOS patients, more investigation is required. Additionally, supplementation with omega-3 fatty acids, folic acid, selenium, vitamin E, catechin, glycyrrhizin, and coenzyme Q10 should be considered in women with PCOS. Research indicates that this type of micronutrient supplementation with PCOS patients improves inflammatory factors, biomarkers of oxidative stress, and metabolic parameters. Lastly, diet modification and exercise prevent the onset of metabolic syndrome and infertility in women, specifically in those who follow a low protein and high fiber diet. This can be achieved on a MD, further suggesting the potential benefits of its adoption among the PCOS population.


The Effectiveness of Dietary Intervention on Polycystic Ovarian Syndrome Management: An Exploratory Literature Review

Background: Thyroid storm is a rare condition but life threatening. Having a high index of suspicion is required especially in patients without previous diagnosis of hyperthyroidism. The increasing use of contrasted iodine studies has caused a resurgence of iodine induced hyperthyroidism which in the most severe cases presents as thyroid storm.
Case Presentation: A 21-year-old female presented with 4 weeks of worsening dyspnea. Associated symptoms included abdominal pain, nausea, vomiting and fever. 3 weeks prior to presentation she underwent CT angiogram of the chest which was negative for pulmonary embolism. She had no past medical history and denied any current medications or recreational drugs. Temperature was 98.4 F, heart rate 107 bpm and blood pressure 125/110. On exam she seemed agitated and anxious. Mild exophthalmos, hyperdynamic precordium, tachycardia, and bilateral pedal edema were also present on exam. Labs showed initial TSH 0.00 uIU/mL, elevated free T4 5.3ng/dL and elevated thyroid receptor antibodies. Pregnancy test was negative. She was diagnosed with thyroid storm and treatment initiated with propranolol, hydrocortisone, methimazole and potassium iodide. Later symptoms improved and she was discharged on propranolol and methimazole with plan to follow-up with Endocrinology.
Discussion: Thyroid storm has multisystem involvement which can mimic other conditions such as sepsis leading to delayed diagnosis. Correct diagnosis requires a complete history and physical examination. Use of the Burch-Wartofsky scale is helpful to support diagnosis of thyroid storm; in the case the Burch-Wartofsky score was 40 suggestive of thyroid storm. Looking for precipitating factors is important. These precipitating factors include infection, myocardial infarction, pregnancy, trauma, and large loads of exogenous iodine (contrast or medications like amiodarone). The phenomenon of hypersecretion of thyroid hormone by autonomous areas within the thyroid gland after an acute iodine load is known as the Jod-Basedow phenomenon. It usually develops within 2 weeks of the iodine load. In patients with symptoms suggestive of thyrotoxicosis, exam findings such as thyromegaly/thyroid bruit, or iodine deficiency, it is suggested to request thyroid hormone assay before an iodine contrasted study. 



The Perfect Storm: Thyrotoxic Crisis Precipitated by Iodinated Contrast

Abstract Title:Bleeding from Jejunal Diverticula
Background: Small intestinal hemorrhage is a common location of obscure GI bleeding and can be difficult to diagnose and treat given the limitations of traditional gastroscopes and colonoscopes. Jejunal diverticulosis is very rare with the prevalence of 0.3-1.9% in studies of the small bowel and 0.3-1.3% in autopsy studies. The presentation varies from being asymptomatic to causing massive gastrointestinal hemorrhage. We present a case of massive obscure GI bleeding from jejunal diverticulosis that was able to be successfully treated by deep enteroscopy with a pediatric colonoscope.

Case Presentation: 68-year-old female with PMH of internal hemorrhoids, osteoporosis admitted with 3-day history of dark tarry stool, mild epigastric pain, and associated dizziness. She had no significant GI history.
On admission, she was hemodynamically stable. Exam showed melena. Her Hg was 6.5 gm/dL. She was started on IV PPI and received 2 units of PRBCs. Esophagogastroduodenoscopy was performed that showed a 2mm non-bleeding ulcer in the gastric antrum, thought to be the source of bleeding, but no longer active. She was discharged home on oral PPI as Hb was stable
Three days later, she returned to the ED with continued evidence of ongoing blood loss with multiple episodes of melena. Admission Hg was 6.0mg/dL. After initial PRBC transfusion and preparation, colonoscopy was performed that showed pan-diverticulosis, but no active bleeding. Deep intubation of the terminal ileum showed fresh blood, but no active source could be identified, indicating the source was in the proximal small bowel. 
Enteroscopy was then performed with a pediatric colonoscope that showed multiple jejunal diverticula. A visible vessel with active bleeding was seen within a jejunal diverticulum. Hemostasis was successful with clips and hemostatic powder

Discussion: Jejunal diverticulosis is rare and can be congenital or acquired. Prevalence increases with age and most commonly presents in the 6th and 7th decade. The etiology is unclear, but possibly due to small bowel dysmotility with increased intraluminal pressure. It is often asymptomatic but can cause severe complications including hemorrhage, perforation, enterolith formation, small bowel diverticulitis and intestinal obstruction.
Deep enteroscopy should be considered in patients with suspected small bowel bleeding. 



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