United States

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&#39;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.

AMA Research Challenge 2023

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

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.

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Join the AMA Research Challenge poster symposium and semifinals to explore top research posters, score posters in the semifinals (an AMA member exclusive opportunity) and attend education sessions with experienced physicians to learn tips to advance your research and career. 

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.

The Last Bite: Development of Nonspecific Allergic Response After Environmental Trigger

Pott Puffy Tumor is a rare disorder commonly seen in adolescent populations and typically arises as a complication of severe sinusitis, leading to osteomyelitis of the frontal bone and presenting as swelling of the forehead. Herein, we report a case of a 46-year-old male with no significant known medical history presenting with seven months of headache. This case highlights the importance of considering Pott Puffy Tumor as a differential diagnosis in adult patients presenting with chronic headache and frontal swelling.

Pott Puffy Tumor in Newly Diagnosed Human Immunodeficiency Virus

Background
Malaria in the United States is a rare disease with a reported number of cases typically 2,000 each year. In 2022, the State of Ohio had 32 malaria cases: 10 females and 22 males. This mosquito born illness poses a major threat to American travelers, military personnel, and US citizens living abroad in endemic areas. In returning travelers from high-risk countries, Malaria is the most common cause of febrile illness. Plasmodium ovale can remain dormant in the liver and presentation will be delayed. Chronic infection and relapsing disease will persist if the infection is not treated in the initial stages. Relapse episodes may occur months or years later. 

Case Presentation
We present a case of a 39-year-old male with a past medical history of chronic pancreatitis, depression, type 2 diabetes mellitus, gastroesophageal reflux disease, recent Epstein- Barr virus infection, who presents with fever, nausea, and vomiting beginning 10 days prior to admission. The patient has an extensive travel history abroad and returned from Angola six months ago. Prior to admission, he underwent treatment at a different hospital for sepsis, encephalopathy, fever, Epstein-Barr virus and babesia. His condition worsened and he left against medical advice and opted to seek treatment at our facility. With concern for malaria, immediate testing included: Giemsa-stained peripheral blood smear and malaria polymerase chain reaction. His anti-malarial treatment regimen included artemether-lumefantrine tablets for 3 days. Plasmodium species PCR was positive for Plasmodium ovale. The patient responded well to therapy, and continued follow-up at the infectious disease clinic. Likely, the progression and severity of his malaria infection progressively worsened due to delays in treatment and testing. Given his travel history, a concern for malaria should have been on the differential diagnosis at his previous hospital admission.

Discussion
Plasmodium ovale and Plasmodium vivax infection can remain dormant for months and will cause relapses despite anti-malarial prophylaxis treatment. An immunocompromised patient with infection can trigger nonspecific host defense mechanisms. The patient’s symptoms were initially attributed to Epstein-Barr virus infection; unfortunately, there was a missed malaria diagnosis. New research suggests climate change is increasing the mosquito population worldwide and likely causing higher malaria cases. Anti-malarial prophylaxis should be initiated and completed in patients traveling to endemic regions. Returning travelers with flu-like symptoms should be evaluated for malaria as soon as possible.


A Case of Plasmodium Ovale Malaria Presentation

Background
Cetuximab is a chimeric antibody used in treatment of metastatic colorectal cancer. Administered via an infusion, the most common side effect of cetuximab is mild allergic response. However, more serious reactions of anaphylaxis and cardiac arrest have been reported. Given the scarcity of the incidence of these reactions, and their reversible nature, there is limited understanding of predisposing factors and essentials of prevention. The present report aims to bridge this gap in knowledge and describes a case of cardiac arrest following cetuximab infusion. 

Case Presentation
A 68-year-old male with a medical history of stage 4 colorectal cancer with metastasis to the lung and liver presented to the emergency department (ED) with cardiac arrest following his first dose of cetuximab as a part of an outpatient clinical trial. Prior to infusion, the patient received 50 mg of Benadryl and underwent an electrocardiogram which revealed no abnormalities. Three minutes following initiation of cetuximab infusion, the patient developed pulseless electrical activity (PEA) and manual cardiopulmonary resuscitation (CPR) was begun. Vitals included a blood pressure of 95/38 mmHg and an oxygen saturation of 73%. En route to the emergency department (ED), the patient was intubated, and manual chest compressions were continued. Upon arrival, Acute Cardiac Life Support protocol was initiated and 2.3 mg of epinephrine was administered. The patient regained cardiac activity after fifteen minutes and was transferred to the critical care unit on an epinephrine drip. 

Initial laboratory testing revealed acidemia with a low bicarbonate level, hyponatremia and hyperchloremia, and normal potassium and magnesium levels. Elevated troponin T levels of (199 ng/L) were observed; however, echocardiography showed no abnormalities except for the slightly prolonged QTC interval in the ECG. Additionally, the patient had a high tryptase level of (63.6 ng/mL), suggesting an anaphylactic response. A CT chest image identified a new large left pneumothorax within a pre-existing subpleural bulla, bilateral rib fractures, and small pleural effusions likely due to recent CPR. The pneumothorax resolved with chest tube insertion. Although the patient initially improved, unfortunately he deteriorated with worsening hypoxia and aspiration pneumonia expired on the eighth day of admission.

Discussion
This case demonstrates the risk of life-threatening acute hypersensitivity responses following chemotherapy infusions, regardless of premedication with antihistamines. It underscores the importance of preliminary allergy testing, close monitoring of electrolytes and tryptase levels during transfusion, and quick access to crash carts.

Next from AMA Research Challenge 2023

Male HIV-1 Viremic Controller: Case Report