United States

Genital dermatoses can severely affect patients’ quality of life, including their sexual life. We sought to examine the impact of genital psoriasis among psoriatic patients, their response to treatments, and how often genital psoriasis is evaluated by dermatologists. A cross-sectional qualitative study was completed. Patients 18 years or older seen for psoriasis by one of the attending dermatologists or those receiving phototherapy from the Massachusetts General Hospital Outpatient Dermatologic Clinic were recruited. Fifty-five subjects were enrolled in the study and completed a 23-item questionnaire. Only 23.6% of participants had ever been asked if they had a genital rash by a dermatologist. 60% of participants indicated a dermatologist had never examined the genital area. 43.6% of participants indicated they had had at some point some form of itching, burning, pain, or involvement in the genital areas. Of these, 45.8% indicated that their dermatologist did not ask/diagnose the genital rash. These patients ranked genital itching 4.61/10, pain 4.09/10, and stinging/burning 3.86/10. 80% of participants indicated that they were self-conscious or experienced some form of embarrassment because of their skin psoriasis. 29.1% of participants described that their overall psoriasis has caused some form of sexual difficulty for them. 50% of participants with involvement in their genital area indicated experiencing some form of sexual difficulty. When looking at the gender breakdown of sexual difficulty, 62.5% of female patients indicated significant sexual difficulty compared to just 25% of male patients. This qualitative study of patients with psoriasis adds to the growing body of knowledge regarding genital psoriasis. It shows that even though almost half of the patients enrolled in the study had a rash or some form of symptoms in their genital regions, a majority of patients had never had their genital area examined by a dermatologist for psoriasis nor had they ever been asked if they had a genital rash. For those patients with symptoms in the genital areas, there was mild to moderate discomfort experienced by patients in regards to pain, stinging, and itching in the genital regions. A majority of these patients, specifically female patients, experienced significant sexual difficulty due to their genital psoriasis. In the future, providers should regularly examine and ask patients with psoriasis about potential genital involvement. Given the significant sexual difficulty and embarrassment patients felt from their skin psoriasis, providers should also ask about the psycho-social burden patients may experience from their psoriasis. 


2023 AMA Research Challenge

Provider evaluation and patient experience among patients with genital psoriasis

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Background
The aging population in the United States is increasing with a concurrent increase in the prevalence of cognitive impairment. Modifiable and non-modifiable risk factors play a role in the pathogenesis of cognitive impairment, including obesity. The association between obesity and cognitive function in older adults is not well characterized. This study aims to examine the longitudinal effect of obesity defined by both Body Mass Index (BMI) and waist circumference (WC) on cognitive function in older adults.
Methods
This study utilized 10 years of data from the National Health and Aging Trends Survey (NHATS), a nationally representative survey of US adults aged ≥ 65. Participants with missing anthropometric data or a diagnosis of dementia at baseline were excluded. Cognitive function was assessed using standardized tests in the cognitive subdomains of memory, orientation, and executive function, as well as an overall cognitive domain. Obesity and overweight were defined as a BMI ≥ 30 and ≥ 25 respectively. High WC was defined as ≥ 88 cm in women or ≥ 102 cm in men. Proportional hazards modeling was used to assess the relationship between obesity and incident cognitive impairment with adjustment for demographic characteristics and comorbidities.
Results
The study included a total of 10,735 participants in the BMI cohort and 10,023 participants in the WC cohort after exclusion criteria were applied. The incidence rate of overall cognitive impairment increased over 10 years of study data in both BMI and WC cohorts from 19.1 to 25.6 and 18.5 to 25.1 per hundred person-years respectively. Higher BMI was associated with a decreased risk of cognitive impairment - participants with obesity-range BMI had an adjusted HR of 0.8 (0.73-0.88), participants with overweight-range BMI had adjusted HR of 0.9 (0.83-0.97), and participants with high WC had adjusted HR of 0.96 (0.89-1.03) for overall cognitive impairment. These associations were consistent across all cognitive subdomains.
Conclusion
This study provides evidence of a protective effect of higher BMI on the development of cognitive impairment in older adults in a dose-dependent fashion. Higher WC did not demonstrate a significant protective cognitive effect. The relationships demonstrated in this study suggest a complex interplay between body composition and neurological decline in this population. Further study is needed into the mechanisms underpinning these findings. These findings have implications for weight management guidelines and interventions in the geriatric population.


Trajectories of Cognitive Decline by Obesity Status in Older Adults

Background
Schistosomiasis, also known as Bilharzia, is a disease caused by schistosomes, a type of trematode or fluke parasite. Transmission occurs through contact with parasite-infested water. There are three major schistosome species that cause severe infection in humans, each with a preference for a specific organ system. The disease is predominantly found in rural areas with inadequate sanitation of freshwater sources and is endemic in Africa, Asia, and South America. Infected individuals excrete schistosome eggs, which hatch and infect freshwater snails, serving as intermediate hosts. The cercariae that develop within the snails can penetrate human skin and enter the bloodstream. Adult schistosomes migrate to various organ systems via the venous system, most commonly affecting the gastrointestinal and genitourinary tracts. Clinical manifestations and chronic inflammation are associated with the presence of schistosome eggs. Schistosomiasis can involve multiple organ systems, with symptoms varying depending on the affected system. Genitourinary schistosomiasis can lead to hematuria, dysuria, and pelvic pain. Diagnosis involves antigen detection, imaging, and tissue sampling. Chronic infection can result in bladder fibrosis and calcification, as well as an increased risk of bladder cancer, particularly squamous cell carcinoma. Early detection and treatment with Praziquantel are crucial in reducing the risk of cancer development.

Case Presentation
A 26-year-old man with a history of intermittent gross hematuria presented to his primary care physician. Previous evaluation at a local hospital revealed a possible clot or mass in the bladder, but further investigation was not pursued. The recent presentation showed gross hematuria with small clots, and urinalysis confirmed the presence of red blood cells. Urine culture, cytology, and STI panel were negative. CT Urogram with contrast revealed plaque-like and nodular wall thickening of the bladder. Cystoscopy showed diffuse white-yellow deposits, and pathology confirmed the diagnosis of schistosomiasis. CT of the abdomen and pelvis was valuable in assessing the extent of involvement. The patient was referred to infectious disease for treatment.

Discussion
As global travel increases, physicians are more likely to encounter uncommon conditions such as schistosomiasis, which may not be endemic to their population or location. Awareness, early detection, and immediate treatment are crucial to prevent long-term complications and improve patient outcomes. This case emphasizes the importance of staying informed about rare conditions and utilizing imaging techniques to provide timely and appropriate care to patients.

A Case Report on Chronic Schistosomiasis

Introduction 
Accurate diagnosis and interpretation of signs and symptoms are crucial for effective patient management. However, there are instances when medical findings can be deceiving, indicating a particular condition or outcome when the situation is more complex or unexpected. 

This distinctive case illustrates such an example of a deceptive, almost benign finding which led to a more portentous diagnosis. Such instances remind us of the ever-evolving nature of medicine and the importance of maintaining a critical mindset when interpreting clinical data. 

Case Presentation 
A 31-year-old, apparently healthy male visited his doctor with concerns about a seemingly innocent rash on his shoulder that had been present for a year. What started as a small, 1x2 cm rash had recently become an elevated 5x7 cm rash and had also started appearing in multiple other parts of his body, like his groin, back, postauricular, scalp, and axillary regions. 

Due to the lesion's persistence, a biopsy was conducted revealing Kaposi Sarcoma (KS). Further evaluation led to the diagnosis of full-blown HIV AIDs with a CD4 count of 12. After ruling out opportunistic infections, he was started on Highly Active Antiretroviral Therapy (HAART) and chemoprophylaxis for Mycobacterium Avium Complex and Toxoplasmosis. 

However, the patient developed odynophagia, oral thrush, cough, and shortness of breath despite being on prophylaxis and was therefore admitted with esophageal candidiasis and Pneumocystis carinii pneumonia, for which he underwent a prolonged course of therapy. 

Discussion 
KS, a multicentric angioproliferative neoplasm, with its distinctive skin lesion gained public attention as an AIDS defining malignancy. Although common during the height of the AIDS epidemic, with the advent of effective HAART therapy, KS has become an uncommon differential. 

A metanalysis of studies between 1967 to 2013 revealed that KS was highest in people affected by HIV (481.54 per 100 000 person-years). 

Studies also report an annual decrease of 3.6% in KS incidence after the introduction of HAART world-wide. 

At the time of presentation, our patient had extensive diffuse KS which served as the tip of the iceberg, which led to his diagnosis and prompt initiation of HAART. 

In conclusion, the significance of possessing a broad clinical knowledge base and exercising the highest level of suspicion cannot be overstated. By embracing a comprehensive approach to patient care and maintaining a healthy skepticism towards clinical presentations, practitioners can enhance diagnostic accuracy, optimize treatment outcomes, and ultimately improve patient safety and well-being. As we navigate the challenges of modern medicine, fostering a culture of continuous learning, critical thinking, and unwavering suspicion will undoubtedly contribute to the advancement of healthcare and the provision of exemplary patient care.

From Innocence to Diagnosis - The Hidden Impact of a Disregarded Rash​

This case report presents a thirty-nine-year-old cisgender MSM patient who has multiple serological confirmations of HIV-1 RNA viral load for more than 12 years. Despite the absence of antiretroviral therapy (ART), this patient has consistently displayed a lack of clinical disease progression and has maintained a relatively low viral load. If not for their viremic controller status, this patient would have likely developed AIDS per the natural history of HIV infection. Over the course of three-months post-intervention, our observation revealed that initiating ART in this HIV-1 positive viremic controller yielded notable increases in CD4 and absolute neutrophil cell counts, accompanied by a reduction in viral load copies to undetectable levels. These findings suggest a substantial decrease in the patient's likelihood of developing comorbidities. Here we analyze the changes in HIV reservoirs before and after the implementation of ART into the treatment plan. Similar cases such as this have been reported, but the literature has yet to gather a sufficient volume to properly inform physicians and scientists on proper management of EC. Disseminating a case of this nature within the medical community holds significant relevance for enhancing our understanding and management of HIV-1 disease progression, improving the quality of life particularly among controllers. Furthermore, future studies investigating the cellular and molecular mechanisms underlying this demonstration of innate immunity hold significant importance in the broader quest for discovering a cure HIV-1.

Male HIV-1 Viremic Controller: Case Report

Emphysematous gastritis is a rare infection caused by gas-forming organisms infiltrating stomach mucosa. Early diagnosis is critical for successful medical treatment and avoidance of associated high morbidity and mortality. Management can be further complicated by potential contribution of fungal infections, particularly in immunosuppressed patients. This case reviews the inpatient conservative management of emphysematous gastritis in an immunosuppressed patient with known Candida esophagitis.

Medical management of emphysematous gastritis precipitated by an azole-resistant Candida infection

A broad differential exists for infectious esophagitis including fungal, viral, and bacterial pathogens. Although often seen in immunocompromised patients, certain risk factors should prompt consideration of unusual etiologies in immunocompetent hosts. This case explores a 24-year-old female with known eosinophilic esophagitis (EoE), initially presenting with odynophagia and globus sensation, found to have HSV esophagitis. It is known that HSV esophagitis predominantly occurs in hosts with impaired immunity resulting from chemotherapy, transplantation, or HIV infection: all risk factors that this patient did not have. This poster presentation explores the pathophysiological relationship between EoE and HSV esophagitis in an otherwise immunocompetent host as well as the role of occupational exposures as risk for primary HSV infection. Our goal is that this case 1) prompts physicians to consider uncommon etiologies for presumed infectious esophagitis to expedite treatment and clinical improvement, and 2) inspires further research into the relationship between EoE and HSV esophagitis as well as the preferred treatment regimen.

A Sticky Situation: Odynophagia and Globus Sensation in an Immunocompetent 24-Year-Old Female

Background
Coronaviruses, including SARS-CoV-2, cause the respiratory disease known as COVID-19. Some individuals experience persistent symptoms, referred to as long COVID. Among the complications reported after COVID-19 are Guillain-Barre Syndrome (GBS) and its variant, Miller Fisher Syndrome (MFS). MFS causes muscle weakness, ataxia, and ophthalmoplegia. Treatment typically includes intravenous immunoglobulin (IVIG) or plasmapheresis. While most COVID-19-associated MFS cases improve with IVIG, this case highlights a patient who did not show symptomatic relief.
Case Presentation
A 57-year-old male with a medical history of prior COVID-19 infection, facial fracture repair, and treated syphilis presented to the emergency department (ED) with sudden-onset double vision, pain behind the left eye, dizziness, frontal headache, and generalized weakness. The diplopia began five days after the initial COVID-19 diagnosis and progressively worsened. The patient had experienced a dry cough and rhinorrhea prior to admission, with a confirmed SARS-CoV-2 infection. On admission, the patient exhibited facial nerve weakness, impaired eye movement, ptosis, diminished reflexes, and generalized weakness. Sensation, cerebellar function, and gag reflex were normal, but the patient required a cane for ambulation. The patient 
underwent a comprehensive evaluation and was diagnosed with Miller Fisher Syndrome. Treatment with IVIG and prednisone was administered, but there was no improvement in symptoms even after 8 weeks.
Discussion
This case report presents a unique case of a patient who developed MFS following a COVID-19 infection. Despite receiving IVIG treatment, the patient did not experience any improvement in symptoms even after 8 weeks. This is a notable finding as most reported cases of COVID-19-associated MFS have shown some improvement after IVIG therapy within 2 weeks. The patient's prolonged lack of symptomatic improvement raises questions about potential modifications of MFS or resistance to standard treatment. Further research is needed to understand the relationship between COVID-19 and MFS, including potential predisposing factors and pathophysiological mechanisms. The case highlights the need for targeted therapies and diagnostic markers for MFS in the context of COVID-19, as well as the importance of early detection and understanding the impact of different strains of the virus on neurological manifestations.



Title of Persistent Miller Fisher Syndrome Following COVID-19 Infection: A Case Report

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**Abstract:**



Saccharomyces cerevisiae (Baker’s Yeast) Pneumonia in an Immunocompromised Host

Background
Shigella is a Gram-negative, facultative anaerobic bacteria that causes a gastrointestinal infection characterized by bloody diarrhea. First-line treatment is azithromycin; however, in the men who have sex with men (MSM) population, Shigella is known for higher rates of azithromycin resistance. Other treatments, including trimethoprim-sulfamethoxazole, fluoroquinolones, and ampicillin, are also increasing in resistance. 

Glucose-6-Phosphate Dehydrogenase (G6PD) is an enzyme that prevents cellular damage from reactive oxygen species (ROS), to which red blood cells are especially susceptible. G6PD-deficiency is an inherited disorder characterized by acute hemolytic anemia after exposure to high levels of ROS from foods and certain antibiotics, including many that are used for treatment of Shigella.

Case Presentation
A healthy 28-year-old male with a history of MSM activity presented to the emergency department (ED) with four days of 15-20 daily episodes of increasingly bloody diarrhea and a recent exposure to a sick contact with similar symptoms. As an Active Duty Sailor, he initially sought care from his ship’s physician who prescribed azithromycin and acetaminophen without relief. In the ED, he was tachycardic and physical exam revealed tenderness of left abdominal quadrants with rebound. Rectal exam showed bright red blood and watery brown stool. Lab work was notable for leukocytosis, acute kidney injury (BUN 40, Cr 3.3), and lactate 2.1. A CT abdomen/pelvis revealed moderate proctocolitis. He reported no known drug allergies, and was given fluids, ciprofloxacin 500 mg, and metronidazole 500 mg for presumed infectious diarrhea. He was admitted to the Internal Medicine Ward, where GI Stool PCR resulted positive for Shigella. Chart review indicated a history of G6PD-deficiency, at which point he was transitioned to ceftriaxone from ciprofloxacin with an Infectious Disease consult. He clinically improved and was discharged home on Augmentin; however his symptoms did not resolve on Augmentin. Culture sensitivities resulted after his discharge, which demonstrated resistance to ampicillin. He was switched to cefpodoxime per Infectious Disease recommendation and recovered fully.

Discussion
This case illustrates the value of complete history gathering in determining a patient’s full spectrum of risk factors. Relevant for this patient was his sexual history and medication intolerances that he did not initially disclose. It also highlights the growing importance of alternative treatment regimens to mitigate the adverse effects of increasing global rates of antibiotic resistance, especially for patients with complex histories and medication intolerances.

Diarrheal Dilemma: G6PD-Deficiency Complicating Treatment of Antibiotic- Resistant Shigella in the MSM Population

The lone star tick (Amblyomma americanum) in the United States spreads diseases such as Ehrlichiosis, Rocky Mountain spotted fever, tularemia, and STARI. Their aggressive biting and covert attachment require immediate removal and avoidance of infested areas. We present a case report of a 28-year-old male entomologist who presented to the emergency department after being bitten by numerous lone star ticks while collecting samples. He experienced skin reactions at the bite sites and was started on doxycycline for prophylaxis. Antihistamines were prescribed, and he was advised to carry an epinephrine auto-injector and avoid allergens. Blood tests showed no abnormalities. Additionally, he developed an alpha-gal allergy from the tick bites, leading to allergies to various foods and environmental factors. This is likely due to the introduction of alpha-gal into the body through the tick bites, leading to an immune response and subsequent allergic reactions. The patient's condition also involves allergies to environmental antigens such as Timothy grass, white oats, and American elm. A personalized dietary plan, avoidance of allergens, and preventive measures against tick bites were recommended. Osteopathic considerations, immunological testing, and referral to an allergist were suggested for further management. He planned to undergo tests for alpha-gal and alpha tryptase but encountered difficulties due to insurance issues. This case highlights the challenges faced by patients in accessing necessary diagnostic tests for tick-related allergies and emphasizes the importance of addressing insurance barriers to ensure appropriate care for individuals at risk. In conclusion, this case highlights the challenges faced by patients in accessing diagnostic tests for tick-related allergies due to insurance issues, underscoring the need to address these barriers to ensure appropriate care for individuals at risk of developing multiple allergies following lone star tick bites.

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Provider evaluation and patient experience among patients with genital psoriasis

Next from 2023 AMA Research Challenge

Trajectories of Cognitive Decline by Obesity Status in Older Adults