United States

Lethal And Rare Side Effect Of Cyclosporin That Is Reversible If
Diagnosed Timely.
Introduction: Posterior Reversible Encephalopathy Syndrome-PRES, is a lethal but reversible condition that is caused due to impairment of cerebral perfusion autoregulatory mechanism. There are limited number PRES cases reported from Cyclosporine and hence wanted to alert the physician community to be more vigilant about closed surveillance of this population who presents with acute neurological changes.
Case Description: 22-year-old male with history of Cystic Fibrosis status post double lung and liver transplant, on cyclosporin presented to the ED after having a witnessed seizure. Patient reports of having severe headache upon waking up that morning, radiating from neck to his occipital area followed by nausea and vomiting which culminated in seizure. Patient also had another episode of seizure in the ED. Patient received Ativan and Keppra. Patient had fatigue but denies any other complains in ED. Vitals were BP-180/121, RR-20, HR-98, T-97.5F and SPO2 98% on 2L NC. On Physical Examination Patient appeared lethargic and had decreased breath sound bilaterally on auscultation of lungs. After the seizure at the hospital patient’s BP normalized. Neurologist and transplant team was contacted, and MRI was recommended along with continuation of Keppra and holding of cyclosporin.
Cyclosporine levels were checked and found to be normal. MRI showed hyperintense FLAIR and T2 signal within cortical/subcortical region of the bilateral occipital, frontal lobes and left cerebellum. The diagnosis of PRES was established. Due to lack of neurology service at our hospital, patient was transferred to another facility for further management. On further investigation it was found out that Patient had once developed PRES syndrome when he was initially on tacrolimus and was later changed to Cyclosporine 2 years back.
Discussion: PRES occurs when cerebral perfusion autoregulation is impaired
resulting in radiographic evidence of vasogenic edema. Presentation includes
neurological symptoms ranging from headache to seizures. Due to its vague
symptoms, PRES is occasionally missed. It is also commonly associated with
Tacrolimus, but we should be aware that any immunosuppressive or
cytotoxic medications can cause this. It is also to be noted that these patients
present with HTN emergency or labile BP but nitroglycerine should never be
used as it can aggravate cerebral edema. PRES is reversible and patients can
recover within weeks if diagnosed timely by rapid control of BP or withdrawal
of offending drug. If diagnosis is delayed or missed Patients can have
permanent neurological injury or even death due to high intracranial
pressure. Recognition of this syndrome is critical to institution of appropriate
therapy and prevention of this lethal outcome. This case illustrates that If a
patient presents with neurologic symptoms as mentioned above, and is
either in hypertensive emergency, has labile blood pressures and is on
cytotoxic agents or immunomodulators PRES should be in the differential
diagnosis.

2022 AMA Research Challenge

Lethal And Rare Side Effect Of Cyclosporine That Is Reversible If Diagnosed Timely.

# Welcome everyone to ACL 2022!

The 60th Annual Meeting of the Association for Computational Linguistics is taking place May 22-27, 2022 as a hybrid event, in Dublin and online. We are happy to welcome all of you to this anniversary edition with an almost 50-50 in-person and virtual participation. 
The main conference program features oral presentations, in-person and virtual posters and demo sessions, a plenary session for our best paper presentations and awards, three amazing keynote events and two new initiatives of invited talks: Spotlight Talks for Young Rising Stars (STIRS) and The Next Big Idea Talks. Posters (including Findings of ACL 2022) and demos are grouped by areas for both the in-person and the virtual sessions. For the virtual component, the talks will be on Zoom and the posters and the demos will be in GatherTown. The Student Research Workshop will have an oral session and a poster session as part of Poster Session 1. The program also features eight Tutorials and 28 Workshops. 

 
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ACL 2022

The Association for Computational Linguistics (ACL) is the premier international scientific and professional society for people working on computational problems involving human language, a field often referred to as either computational linguistics or natural language processing (NLP). 

poster

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 **Speakers**
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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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Registration Is Required

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


Mycobacterium abscessus complex (MABc) is part of the rapid-growing non-tuberculous mycobacteria group that usually resides in natural water sources. When it affects humans, it can be highly resistant and difficult to manage. The most common presentation is localized, mainly in the lungs and soft tissue, but can be generalized in immunocompromised patients. Here we present a case report of a 40-year-old female with a chronic infection of the abdominal wall after abdominoplasty.

A Rare Insidious Case Of Skin And Soft Tissue Infection Due To Mycobacterium Abscessus: A Case Report

Gastrointestinal stromal tumors (GIST) are the most common type of gastrointestinal tract mesenchymal tumors. They are typically characterized by activating mutations in the KIT or PDGFRA oncogenes. They usually present incidentally or with chronic and nonspecific symptoms like bloating, early satiety, fatigue, or anemia in patients over the age of 60 years. Approximately 5% of cases will present with an abdominal mass. Up to 10% of GISTs will present with advanced disease where the primary tumor is difficult to establish. We present a case here of a metastatic GIST with an unusual and late presentation, with a palpable abdominal mass, and without an obvious primary tumor on initial CT/ MRI imaging. 


Metastatic Gastrointestinal Stromal Tumour: A Rare Case

Nivolumab is a monoclonal antibody which blocks PD-1. It acts a checkpoint inhibitor and is used both alone and in combination to treat variety of cancers like melanoma, non-small cell lung cancer,squamous cell cancers of head and neck among others.Here we present a rare case of nivolumab induced hypothyroidism presenting as a case of severe hyponatremia.

Nivolumab induced hypothyroidism presenting as a case of severe hyponatremia

OMG, a Case Report

Posterior Reversible Encephalopathy Syndrome in the Setting of Uncontrolled Hypertension and Diabetes Mellitus

Role of Shoulder Injury Related to Vaccine Administration (SIRVA) in the COVID-19 Pandemic

Septic arthritis of the TMJ is a rare bacterial infection of the joint space, with a reported incidence of 2 to 10 cases per 100,000 patients. Its uncommonness in the clinical setting has led to a corresponding scarcity in the literature, and as a result, SATMJ has no definitive management guidelines in place. Owing to dangerous sequelae including abscess formation or total joint destruction, it is all the more essential to provide rapid therapeutic intervention. Here we present a case of a patient with a history of chronic mastoiditis and otitis media as well as skull base osteomyelitis, who presented with symptoms concerning for SATMJ. Our patient was a 62-year-old male who presented from a nursing facility with one week of progressive left-sided facial swelling and pain. Though the patient was afebrile and had a normal white blood cell count, CT imaging of the maxillofacial bones showed erosive changes at the left TMJ, most consistent with septic arthritis, and an adjacent multilocular abscess. The patient was placed on empiric vancomycin and zosyn; drainage of the abscess by ENT yielded 2 mL of purulent fluid, though culture was negative. The patient’s pain and swelling subsequently improved, and he was discharged with a four-week course of daptomycin and cefepime. Common etiologic factors in SATMJ include contiguous spread from nearby infectious sources. Our patient’s triad of oromaxillofacial pathologies appears to be unique in the literature, and further reflects the role that local infection can play in seeding the joint. Staphylococcus aureus is the most common offending organism, with Neisseria and H. flu also isolated on occasion. However, due to the prompt initiation of antibiotics in presenting patients, joint aspirate is often found to be sterile. Owing to the ambiguity of presenting symptoms and laboratory values, imaging via CT or MRI is considered the most accurate method of diagnosis. Treatment of SATMJ is accomplished through dual therapy of proper antibiotic coverage and drainage of the joint space. As seen in our patient, rapid detection and an equally timely treatment of his condition resulted in a positive clinical course and a successful outcome.

Septic Arthritis of the TMJ in the Setting of Mastoiditis, Otitis Media and Skull Base Osteomyelitis

Introduction:
Spinal stenosis is the narrowing of intervertebral foramina most commonly caused by degenerative changes in the vertebral bodies. Other common causes include achondroplasia, ankylosing spondylitis, or Paget disease. We report a case of a 32-year-old male who presented with difficulty walking and was found to have a rare culprit, spinal epidural lipomatosis (SEL).

Case Description:
A 32-year-old obese male presented with an eight-month history of progressive bilateral leg weakness and back pain, with acute worsening in the past two weeks. He also had associated bilateral lower extremity pain, weakness, numbness, and multiple mechanical falls in the past six months. On physical exam, he was afebrile and normotensive with BMI of 38. He was A/A/O x 4, with neurologic exam significant for muscle strength 2/5 in left leg, 3/5 in right leg, and 5/5 in bilateral upper extremities. He had diminished sensation below L3 in both legs, +4 bilateral patellar reflex with clonus, and upgoing bilateral plantar reflexes. Labs showed normal levels of cholesterol, triglycerides, hbA1C, and TSH. MRI thoracic and lumbar spine revealed spinal cord stenosis with cord compression and myelopathy at T5-T6 due to left central disc extrusion, thickening of ligamentum flavum, and diffuse dorsal epidural lipomatosis. Neurosurgery was consulted, and he underwent urgent T5-T6 decompressive laminectomy with partial T4-T7 laminectomies for evacuation of epidural lipomatosis. At the time of discharge to a rehabilitation facility, his weakness improved in lower extremities with 4/5 muscle strength bilaterally. 

Discussion:
Spinal epidural lipomatosis is seen in 2.5% of population and is caused by excessive adipose tissue in the epidural space. The exogenous steroid group represents 55.3% cases, while obesity-associated disease represents 24.5%. In our patient, obesity may be a driving factor for SEL. SEL is most common in patients taking exogenous steroids, such as post-transplant patients. SEL is also seen in people with type 2 diabetes mellitus, increased production of endogenous steroids, HIV on protease inhibitor therapy, Scheuermann's disease, and those on androgen antagonist therapy. 
Management of SEL depends on the presentation. With acute neurologic deficits, the first-line treatment is urgent surgical decompression. Conservative management of inciting features is recommended if there is a slowly progressive disease. It includes cessation of steroids and treatment of endocrinopathies. Weight reduction has been shown to significantly reduce SEL in obese patients, with one report recommending at least 15 kgs of weight loss to help control symptoms. If conservative therapy is not successful, decompressive surgery such as laminectomy with or without removal of fatty tissue can be considered. Removing as much fatty tissue as possible avoids post-surgical complications. Unfortunately, mortality rate within one year after surgical decompression is as high as 22%.


Spine strangler: A case of spinal epidural lipomatosis in a young male

INTRODUCTION:

Gastrointestinal (GI) manifestations are most frequently reported extra-pulmonary symptoms of COVID-19 infection with a prevalence of 10%-50%. Most common are nausea, vomiting, diarrhea, and abdominal pain. GI perforation especially spontaneous colonic perforations are rare in the disease course.


METHODS:

We report a patient with COVID-19 infection, who developed cecal perforation while recovering from COVID pneumonia, necessitating emergent surgical treatment, and the current literature was reviewed.
65-year-old male presented with shortness of breath, myalgias and fever. He was admitted to ICU secondary to acute hypoxemic respiratory failure due to COVID 19 pneumonia. He was treated with steroids, tocilizumab and remdesivir. On day-11, he developed severe abdominal pain with worsening leukocytosis. His imaging showed large pneumoperitoneum, suggestive of a perforated viscus. He underwent emergent laparotomy and was found to have non-obstructive cecal perforation. A colonic de-tension and right colectomy with ileo-transverse anastomosis was performed. The tissue pathology showed distended colon, active colitis, transmural granulocytic inflammation, and ulceration suggesting bowel perforation.


RESULTS:

ACE2 protein, a cell receptor for SARS-CoV-2, is in glandular cells of gastrointestinal epithelia. Direct viral infection, small vessel thrombosis, or nonocclusive mesenteric ischemia can cause spectrum of bowel findings. SARS-CoV-2 can have direct inflammatory effect on vascular endothelium too. Use of steroids, tocilizumab and systemic coagulopathy seen in severe COVID-19 infection also contributes to these manifestations. In our patient, an acute over-distension of colon, without mechanical distal obstruction, in the setting of COVID-19 infection & tocilizumab led to cecal perforation. Our literature review confirmed only 33 case-studies of bowel perforation in the setting of COVID-19 infection have been reported, with combined 28.5% mortality rate. Considering the worldwide incidence of this pandemic, it is a rare complication.


CONCLUSIONS:

GI perforation is a rare but dangerous complication of COVID-19. Treatment with interleukin-6 inhibitors or steroids is often associated in most cases. Our case underlines the need to be vigilant for severe GI symptoms in setting of COVID-19 infection to improve patients’ outcome.


Spontaneous Colonic Perforation as an unusual presentation of COVID-19 infection: Case Report and Review of literature

Background: Familial Mediterranean fever (FMF) is a rare autosomal recessive, autoinflammatory disease that causes recurrent attacks of fever and acute inflammation in the body. Here we have a case of a clinically diagnosed FMF pt who has a monoallelic mutation of the MEFV gene. This case is unique as the specific monoallelic mutation found has not been reported to cause FMF on its own.

Case Presentation: 13 yo male presents with 2-year history of frequent fever occurring 2-4 times per week accompanied with feeling unwell. Fevers range from 100.5-101 F, resolve with Tylenol, and can occur with sore throat and abdominal pain. No chest pain, joint pain, or rashes present. Genetic testing and evaluation revealed pt is a heterozygous carrier of a pathogenic variant in the MEFV gene, c.2177T>C (p.Val726Ala). FHx of Ashkenazi Jewish ancestry and SLE on maternal side. Workup of UA, CRP/ESR, liver + BMP, and CBC were unremarkable. Diagnosed patient with FMF type I and started on colchicine trial of 0.9 mg daily which improved symptoms. Raised to 1.5 mg daily after pt tolerated trial and symptoms significantly improved. Clinical diagnosis for FMF based on Tel Hashomer Criteria and improvement of symptoms with colchicine trial.

Discussion: FMF is the most common of the known autoinflammatory diseases. The recessive gene for FMF, MEFV, is carried by Ashkenazi Jewish, Turkish, Arabian, Mediterranean, and Middle Eastern populations. This gene encodes pyrin, a protein thought to regulate inflammation through the IL-1 signaling pathway. Severe heterozygous mutations can sometimes cause FMF in a monoallelic form, but this patient’s specific mutation has previously not been found to cause FMF. This is a unique case which demonstrates a Val726Ala heterozygous mutation to cause clinically significant FMF. Also, this case provides an opportunity to demonstrate proper treatment for this patient presentation. 


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Lethal And Rare Side Effect Of Cyclosporine That Is Reversible If Diagnosed Timely.

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A Rare Insidious Case Of Skin And Soft Tissue Infection Due To Mycobacterium Abscessus: A Case Report

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