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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 156-176

Scientific Abstracts from the 2017 Summa Health System's 25th Annual Postgraduate Day

1 Department of Obstetrics and Gynecology, Summa Health System, Northeast Ohio Medical University, Akron, Ohio, USA
2 Department of Surgery, Summa Health System, Northeast Ohio Medical University, Akron, Ohio, USA
3 Department of Internal Medicine, Summa Health System, Northeast Ohio Medical University, Akron, Ohio, USA
4 Department of Family Practice, Summa Health System, Northeast Ohio Medical University, Akron, Ohio, USA
5 Department of Surgery and Integrated Medicine, Summa Health System, Northeast Ohio Medical University, Akron, Ohio, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Michael S Firstenberg
Department of Surgery (Cardiothoracic), Akron City Hospital, Summa Health System, 75 Arch Street, Suite 407, Akron, Ohio 44309
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_55_17

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How to cite this article:
Gil KM, Subichin MP, Tatar K, Alcivar Franco DF, Yevtukh M, Firstenberg MS. Scientific Abstracts from the 2017 Summa Health System's 25th Annual Postgraduate Day. Int J Acad Med 2017;3:156-76

How to cite this URL:
Gil KM, Subichin MP, Tatar K, Alcivar Franco DF, Yevtukh M, Firstenberg MS. Scientific Abstracts from the 2017 Summa Health System's 25th Annual Postgraduate Day. Int J Acad Med [serial online] 2017 [cited 2021 Jan 25];3:156-76. Available from: https://www.ijam-web.org/text.asp?2017/3/1/156/209855

Guest Editors

Background Information: Summa Health will host the 25th Annual Postgraduate Day activities in 2017. The events of the day will celebrate the accomplishments of residents and fellows from many disciplines and recognize their scholarly research productivity. This annual event serves as a testimony to Summa Health's commitment to graduate medical education, which helps in fulfilling its mission to provide the highest quality, compassionate care to the citizens of our region. The Scientific Research Sessions begin with the display of posters. There will also be an interactive session in which the presenters have the opportunity to discuss their research with the postgraduate day judges and other members of the clinical and research community. Oral presentations of the selected abstracts will highlight some of the outstanding resident efforts. Research papers are presented in the categories of Basic Science, Clinical Research, Health Care Education Research, and Quality Improvement studies. Many of the day's accepted abstracts are published here. However, as many of the abstracts have already been submitted, or are in the process of being submitted, to other peer-reviewed journals or scientific meetings, they are not included in this special edition to avoid the potential risk of inappropriate dual publication. Nevertheless, the overall goal is to highlight the impressive scholarly activities of so many members of the Summa Health Community.

The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, Patient care, System-based practice.

Health Care Education Research Category

  Abstract Number 1 Top

Obstetrics/Gynecology Intern Bootcamp: Implementing a Hybrid Learning Curriculum Combining Didactic Lectures and Simulation to Establish the Accreditation Council for Graduate Medical Education Milestone Level One for Incoming Residents

Derek Ballas, Rami Ahmed1, Megan Cesta

Departments of Obstetrics and Gynecology and 1Emergency Medicine, Summa Health System, Akron, Ohio, USA

Purpose/Objective: The purpose of this study is to monitor residents' progression across the Accreditation Council for Graduate Medical Education (ACGME) milestones by assessing participants' knowledge, confidence, and skills in the management of obstetric (OB) emergencies.

Methods: OB/Gynecology (Gyn) interns in July participated in a month-long curriculum consisting of a lecture series covering operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, and hypertension disorders of pregnancy each week over the month. Before initiating the curriculum, the learners took a comprehensive knowledge assessment and confidence survey and participated in a comprehensive simulation on the topics to be covered throughout the month. The simulations were graded on successful completion of predetermined critical actions across the various ACGME milestones by three core teaching faculty members. During the curriculum, didactic lectures were reinforced with weekly high-fidelity simulations on the topics covered. At completion of the curriculum, summative written examination, confidence surveys, and simulation were performed and assessed by core faculty as above. Data analysis included nonparametric analysis of confidence scores and Student's t-test analysis of knowledge assessment scores and critical action scores.

Results: Five OB/Gyn interns from a single institution participated in the hybrid curriculum. Total confidence improved from pre- to post-confidence survey (P < 0.001) and was statistically significant in all areas, except postpartum hemorrhage (P = 0.079). Improvement was seen in comprehensive knowledge assessment. However, total change in cognitive ability was not statistically significant (P = 0.158). Competency assessed by critical actions was found to be not statistically significant (P = 0.218–0.507). Nonstatistically, significant improvement based on completed critical actions was seen in all areas, except shoulder dystocia.

Conclusion: A hybrid curriculum combining didactic lectures reinforced with high-fidelity simulation provides an opportunity to objectively measure participants' baseline knowledge, confidence, and skills. Poor reliability among observers utilizing specific critical actions reinforces the challenges of creating and utilizing a universal tool to track resident performance. A standardized assessment tool provides opportunity to identify and address knowledge deficiencies of incoming OB/Gyn residents while establishing a baseline for the milestone project. Utilizing a hybrid curriculum provides a means to improve both knowledge and confidence of incoming residents.

Quality Improvement Category

  Abstract Number 2 Top

Colon Surgical Site Infection: Quality Improvement Project

Sheridan Morgan, Virginia Abell1, Joel Porter

Department of General Surgery, Summa Health System, 1Infection Control and Clinical Safety, Summa Health System, Akron, Ohio, USA

Purpose/Objective: The purpose of this study was to create a standardized prophylactic antibiotic regimen for patients undergoing colorectal surgery at the Summa Akron City Hospital aimed at preventing surgical site infection (SSI). The incidence of SSI in patients undergoing colorectal surgery at Akron City Hospital is 5%–6%, which is in line with national averages (2.0%–14.5%) based on data from the National Surgical Quality Improvement Program database. Recent studies have shown reductions in SSI rates after implementation of targeted prophylactic antibiotic regimens. We believe that by performing a retrospective analysis of SSIs of colorectal surgery patients from our institution, we will be able to implement an evidence-based institution-specific prophylactic antibiotic regimen for colorectal surgery patients, which will help prevent SSI in the patients at our hospital.

Methods: We performed a retrospective analysis of bacteria isolates from SSIs in patients who had undergone surgery of the large intestine at our institution from July 2009 to July 2016 to characterize the bacterial causes of these SSIs. We used these data to define the species-specific bacterial causes of SSIs in our colorectal surgery patients. We then looked at antibiotic resistance patterns in these bacterial samples and compared these data with institution-specific antibiogram data to determine antibiotic resistance patterns in the bacteria causing SSIs in the colorectal surgery patients at our institution.

Results: The culture data gathered in this study showed high rates of infection with the anaerobic bacteria Bacteroides fragilis and with Gram-negative bacteria, including  Escherichia More Details coli, Pseudomonas aeruginosa, and Enterobacter species. Both the resistance patterns of the isolated bacteria and institution-specific antibiogram data of these Gram-negative bacteria species showed high rates of resistance to first- and second-generation cephalosporin antibiotics.

Conclusions: In this study, we found that SSIs in colorectal surgery patients at the Summa Akron City Hospital are caused by B. fragilis and Gram-negative bacterial species with high levels of resistance to first- and second-generation cephalosporins. We used these data, along with our institution-specific antibiogram data, to create a preoperative antibiotic prophylaxis protocol which is in line with national recommendations that target the species causing SSIs in our colorectal surgery patients. Our new first-line antibiotic prophylaxis regimen for routine use with patients undergoing colorectal surgery at our institution is a combination of ceftriaxone and metronidazole. This combination of antibiotics has better coverage against the bacterial species causing SSIs at our institution, has a good safety profile, and is in line with national recommendations making it an ideal choice for antibiotic prophylaxis in patients undergoing colorectal surgery at the Summa Akron City Hospital.

  Abstract Number 3 Top

Impact of Transesophageal Echocardiography in the Management of Patients with Neurologic Deficits in Sinus Rhythm

Chinedu Igwe, Mark Saling, Jordan Thomas, Roger Chaffee

Department of Cardiovascular Medicine, Summa Health System, Akron, Ohio, USA

Purpose/Objective: The diagnostic and therapeutic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischemic stroke or transient ischemic attack (TIA) in sinus rhythm remains controversial.

Methods: A retrospective chart review was performed for this quality improvement initiative to estimate the prevalence of cardioembolic causes seen in the TEEs and how often these findings changed management in patients admitted with cerebrovascular accident (CVA) or TIA, between 2013 and 2015. The incidence of these findings was compared between male and female patients and also between patients ≤50 years and those >50 years.

Results: TEEs were reviewed in 178 consecutive patients. The mean age was 61 ± 30 years (95 men and 83 women); 39 patients were ≤50 years and 139 >50 years. Of all these patients, 7 (4%) had TIA while 171 (96%) had CVA. A total of 52 patients (29.2%) had abnormal findings in their TEE. Twenty-four (13.4%) patients had patent foramen ovale (PFO), 5 (2.8%) had atrial thrombi, 1 (0.6%) had an atrial mass, 4 (2.2%) had spontaneous echo contrast, 2 (1.1%) had vegetations, 12 (6.7%) had mobile aortic atheroma, 12 (6.7%) had aneurysms, and 1 (0.6%) had an atrial septal defect. The TEE resulted in medication changes in 13 patients (7.3%), 11 patients (6.1%) were started on anticoagulants, 2 (1.1%) had anticoagulants stopped, 1 (0.6%) was started on antibiotics, and 1 (0.6%) had their antiplatelet medication stopped. The TEE findings did not result in change of level of care in any of the patients. There were no gender differences in the incidence of PFO or frequency, in which findings resulted in changes in management, 11 (13%) versus 13 (14%), P = NS, and 4 (5%) versus 9 (10%), P = NS, respectively. Between patients ≤50 years and those >50 years, there was no statistically significant difference in the incidence of PFOs, 7 (18%) versus 17 (12%), P = NS, or the frequency in which the findings resulted in changes in their management, 4 (10%) versus 9 (7%), P = NS. There was a statistically significant difference in the incidence of atrial thrombus and mobile atheromas between patients ≤50 years and those >50 years, 0 (0%) versus 5 (4%), P< 0.05, and 0 (0%) versus 12 (9%), P< 0.05, respectively.

Conclusion: TEEs done in patients with CVA/TIA lead to the identification of abnormal findings in many cases. There was no difference in the incidence of PFO between genders or patients older or younger than 50 years. However, atrial thrombus and mobile arteromas were more common in patients older than 50 years. The frequency in which these findings result in changes in management is much less, with no difference between genders or patients ≤50 years and those >50 years.

  Abstract Number 4 Top

Building Mental Wellness

Pascale Ferdinand, Karen Kirk

Department of Family Medicine, Summa Health System, Akron, Ohio, USA

Purpose/Objective: Mental health in children and adolescents is often an area where primary-care providers may not feel confident in how to assess and manage their patients. This unfortunately promotes a culture where opportunities for early intervention are missed and patient safety can be compromised. We planned to improve mental health outcomes among targeted populations in primary care by providing tools to facilitate early identification and proper assessment of mental health concerns.

Methods: In the ambulatory setting, we implemented the Ages and Stages Questionnaire at the 9, 18, and 30-month well child visits, the Modified Checklist for Autism in Toddlers among toddlers aged 18, 24, and 30 months, and the Patient Health Questionnaire among children and adolescents aged 12–21 years. Team-centered interventions included interactive lectures before launch, as well as throughout the project time frame, working one-on-one with providers to score the above tools and provide referral if necessary, and reminders to the physician before seeing patients.

Results: There was a marked increase in the identification of mental health concerns among patients, as well as subsequent management and referral. Physician confidence at assessing these patients and providing an effective care plan also improved as denoted by survey responses. Methods of implementation that were more successful at ensuring consistency included working individually with providers and reminders to physicians at the start of office.

Conclusion: Building mental wellness in primary care is important for proper management of mental health concerns and overall patient safety, by preventing delays in patient care. This is directly correlated with how confident physicians feel at identifying these concerns and successfully providing effective care to their patients.

  Abstract Number 5 Top

Improving Mammogram Completion Rates through Multimodal Interventions

Maryana Yevtukh, Lynn Hamrich, Mustafa Culcuoglu, William Smucker, Everett Logue

Department of Family Medicine, Summa Health System, Akron, Ohio, USA

Purpose/Objective: In 2016, the Family Medicine Center had a mammogram completion rate of 53%, which is below a suggested target of 80%. Literature suggests that a multifaceted approach, including outreach phone calls, improves screening rates. The purpose of this quality improvement project was to use telephone and electronic outreach to improve breast cancer screening rates.

Methods: An EMR database was used to generate a list of 213 eligible patients. Summa Central Scheduling called these patients to schedule mammograms. One month later, 76 patients with an activated online patient portal account were sent an electronic reminder message. Mammogram completion rates were analyzed at pre-intervention and at 6 months.

Results: After 6 months, the mammogram completion rate increased 12.2% from 51.5% to 63.7%. When contacted by Central Scheduling, 30% of patients scheduled their mammogram, 21% declined to schedule, and 38% were not reached after three attempts.

Conclusions: A multimodal intervention consisting of telephone calls and electronic portal messages increased breast cancer screening rates by approximately 12% in our patient population within the studied 6-month period. This rate of improvement is similar to other multimodal outreach studies. This demonstrates the potential efficacy of a simple intervention to improve health screening rates. We will continue outreach and investigate other strategies to improve breast cancer screening rates.

  Abstract Number 6 Top

Are Clinical Triggers Helpful in Identification of Palliative Patients in Emergency Department?

Shirley Thomas, Steven Radwany

Department of Hospice and Palliative Medicine, Summa Health System, Akron, Ohio, USA

Purpose/Objective: Studies have clearly demonstrated the benefits of early palliative care interventions for acutely ill patients admitted to the Emergency Department (ED). The benefit of palliative care within the scope of ED practice is clearly endorsed by the national emergency medicine bodies as is demonstrated in the 2013 Model of the Clinical Practice of Emergency Medicine. A “trigger list” to identify palliative patients for direct admission to the acute palliative care unit (APCU) was established by the palliative care team in consensus with the emergency team at Summa Akron City Hospital. The aim of this cohort study is to identify whether the “trigger list” has helped identify and admit appropriate patient group to the acute palliative unit floor and through this avoid unnecessary and nonbeneficial interventions.

Methods: Electronic data of all patients admitted from ED directly to APCU were obtained for 1 year (June 2015–July 2015). The data obtained were then captured on an Excel 2007 document. Demographics collected were age, admit date to the ED, admit date to APCU, patient type (known hospice or not) along with their diagnosis, and destination of discharge. Descriptive statistics using Excel's analysis add-in was used for data analysis.

Results and Conclusion: With be presented at a later time.

Case Reports

  Abstract Number 7 Top

Coronary Aneurysm with Retrograde Flow

Iliana S. Hurtado Rendón

Department of Cardiovascular Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Coronary artery aneurysms are dilatations of arterial segment, which are typically incidentally identified during cardiac angiography. The most common etiology is atherosclerotic coronary artery disease, followed by congenital or inflammatory or connective tissue disorders. The incidence of coronary artery aneurysms ranges from 0.3% to 5.3% of the population.

Case Study: A 77-year-old female with multiple medical problems including a history of a remote coronary artery bypass grafting in the past came to our Emergency Department complaining of dyspnea at rest that started 4 days before her visit. The patient was admitted to our Heart and Lung Unit (HLU); she had an echocardiogram that showed a decreased left ventricular function at 35% without wall motion abnormalities. She was taken to the cardiac catheterization laboratory. Her cardiac cath showed multiple coronary aneurysms in the distal left main coronary artery, proximal and left anterior descending (LAD) artery [Figure 1]. A chronic total occlusion of the proximal portion of the right coronary artery was also found. The cardiac catheterization also reported the absence of antegrade flow through the left internal mammary artery (LIMA) to LAD, but the presence of positive retrograde flow from native LAD to LIMA graft. No acute stenotic lesions were identified; percutaneous coronary intervention was not done. After cardiac catheterization, the patient was found with atrial fibrillation and hypotensive. She was started on vasopressors and monitored in the HLU.
Figure 1: Large coronary artery aneurysm in distal left main

Click here to view

Conclusion: Disturbances in blood flow filling and washout can be present in coronary artery aneurysm. Angiographic signs of turbulence and stagnant flow include delayed antegrade dye filling, segmental backflow phenomenon, and local deposition of dye in the dilated coronary segment. In this case, this turbulent phenomenon was present with the absence of antegrade flow from LIMA to native aneurysmal LAD, but a positive retrograde flow from the native vessel to LIMA. With the increasing use of angiography and other diagnostics methods such as high-resolution computerized tomography scans and magnetic resonance imaging, the diagnosis of coronary aneurysm is likely to become more frequent. As our knowledge of pathophysiology and natural history of these lesions can grow, also treatment and outcome for patients continue to improve.

  Abstract Number 8 Top

An Unexpected Case of a “Giant” Pulmonary Artery Aneurysm

Juan Pablo Rodriguez-Escudero, Diego Alcivar Franco, Joseph Pietrolungo

Department of Cardiovascular Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Pulmonary artery aneurysm (PAA) is a rare anomaly of the pulmonary vasculature. Only a few cases have been reported in the literature worldwide, and appropriate management remains uncertain.

Case Study: We report a case of a 53-year-old obese African-American female with a history significant for ischemic cardiomyopathy status, postpercutaneous coronary intervention, and implantable cardioverter defibrillator placement 10 years ago who presented with acute onset of retrosternal chest pain, pressure type, moderate in intensity irradiated to her back, lasted 30 min, resolved with time, and was associated with minimal exertion dyspnea and fatigue; symptoms that have happened intermittently this year. On physical examination, her vital signs were heart rate 98 bpm; blood pressure 130/80 mmHg, respiratory rate ×16/min, temp 37.1°C, and 96% O2 saturations with 2 L nasal cannula; a loud pansystolic murmur heard along the left lateral border of sternum accompanied by mild bibasilar crackles and trace lower extremity edema. Electrocardiogram showed a left fascicular block with right ventricular hypertrophy. Initial work-up in the Emergency Department led to a computerized tomography chest with contrast, which found a PAA of 6.0 cm at the root that extended bilaterally from the main pulmonary artery, without the presence of dissection, pulmonary embolism, or other anatomical anomaly. Cardiology was consulted for further care and management. She had signs and symptoms correlated with New York Heart Association III, Stage C heart failure (HF); a 2D echocardiography was done and showed dilatation of the right atrium and ventricle, moderate tricuspid and pulmonary valve regurgitation, left ventricular ejection fraction 40%. Her clinical picture and new dilated cardiomyopathy drove to a left heart catheterization that revealed non-occlusive coronary artery disease (CAD) with patent previous stents; right heart catheterization with a pulmonary angiogram showed the PAA with moderate pulmonary regurgitation and severe pulmonary hypertension. After diuresis and medical therapy for CAD and HF, the structural heart team approach was taken and consulted, which based on size, extension of aneurysm, valve compromise and progression of her symptoms, the decision of surgical intervention was made with successful aneurysmorrhaphy and pulmonary valve replacement. Postoperative recovery was delayed due to respiratory failure, requiring ventilatory support; however, the patient was progressively extubated and adequately discharged.

Conclusion: This report highlights an uncommon case of PAA successfully managed with favorable outcome. There is no clear guideline for the best therapeutic approach, and there is limited experience because of the infrequency of the disease. We would like to inform our staff on the diagnosis and therapeutic options of this unusual disease that can become symptomatic and life-threatening.

  Abstract Number 9 Top

Portal Vein and Splenic Vein Thrombosis in Crohn's Disease: A Single Case Report

Ashley Coleman-Walker, Joan Kolodzik

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Venous thromboemboli (VTE) affect about 1 in every 300 adult Emergency Department (ED) patients and are associated with high mortality. Inflammatory bowel disease (IBD) is a known risk factor for primary and recurrent VTE. The risk of VTE is roughly increased in proportion to the severity of underlying disease, and an acute flare-up can be regarded as a prothrombotic condition. Deep venous thrombosis and pulmonary embolism are the most common sites for VTE; however, we present a case of portal and splenic vein thrombosis in a patient with a history of Crohn's disease.

Case Study: A 28-year-old male with a history of Crohn's disease and total colectomy presented to the ED with left-sided abdominal pain. Symptoms began 3–4 days prior, with progressive worsening. The pain was an intense, intermittent cramping sensation that lasted 1–2 min and radiated to his left shoulder. He denied exacerbating or relieving factors and rated his pain 6/10. He was currently on week 6 of an 8-week course of prednisone for a Crohn's flare-up. He also noticed a temperature of 102°F the day prior and increased ostomy output without blood or mucus in the stool. Physical examination was remarkable for mild tenderness to palpitation of the left quadrants without guarding, rebound, or masses. His ostomy was noted to have minimum stool. Morphine and ondansetron were given to address his symptoms. Initial laboratories were within normal limits except a leukocytosis of 16.1 uL, possibly a result of steroid use. On reevaluation, he reported only minimally improved of pain. Computed tomography of the abdomen demonstrated a massive thrombosis of the portal and splenic veins. The findings were discussed with surgery, who stated that this pathology only required medical management. The patient was admitted to the medicine service and started on prednisone. Hematology and gastroenterology services were consulted. The patient was discharged 4 days later, with a prescription for apixaban and gastroenterology follow-up.

Conclusion: Increased risk of VTE in patients with IBD is well described. Of all VTEs in IBD, 10% were located in sites such as portal, superior mesenteric, splenic, internal jugular, and sinus veins. A higher rate of thrombosis in the abdominal veins is expected given the primary location of inflammation in IBD is in the gut. VTE should be high on the differential diagnosis in patients with IBD, especially those with an acute flare-up. Physicians should recognize that IBD is a risk factor for prothrombotic state and the possibility of VTE involving venous structures supporting the gastrointestinal tract.

  Abstract Number 10 Top

Finding Methicillin-resistant Staphylococcus aureus in an Unlikely Place

Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) is commonly associated with skin and soft tissue infections, particularly nosocomial skin and soft tissue infections. More rarely, MRSA has been found to infect the respiratory and biliary tracts. While still less common than Streptococcus pneumoniae, Haemophilus influenzae Type b, and viral pneumonia, MRSA pneumonia is an increasingly common cause of hospital-acquired pneumonia. In recent years, there has also been an increasing incidence of MRSA cholecystitis. Fourteen cases of MRSA cholecystitis have been reported in the literature to date.

Case Study: A 70-year-old Caucasian male presented with shortness of breath and altered mental status. He had a medical history of atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, Type 2 diabetes, and ulcerative colitis and a surgical history of a colectomy with colostomy. The patient's Emergency Department work-up identified that the patient was in septic shock with a leukocytosis of 23000/μL and a lactate of 2.7 mg/dL. The chest X-ray revealed bilateral lower lobe infiltrates. Given the patient's septic shock and decreased mental status, the patient was intubated, fluid resuscitated, pancultured, and started on vancomycin and piperacillin-tazobactam. Despite adequate fluid resuscitation, the patient remained hypotensive and was started on norepinephrine. Despite these measures, the patient's lactate trended up to 9.6 mg/dL and his leukocytosis continued to trend up. A computed tomography of the abdomen and pelvis revealed findings that were suggestive of acute cholecystitis. Surgery and infectious disease were consulted, and the patient had percutaneous drainage of his gallbladder the following day. The patient's blood cultures were noted to be positive for MRSA. Percutaneous drainage of the gallbladder evacuated brown purulent fluid, which was positive for MRSA. Following drainage of the patient's gallbladder, his leukocytosis began to trend down and his lactic acidosis resolved. The patient was eventually weaned off vasopressors and extubated. Infectious disease did recommend cholecystectomy once the patient was more stable for definitive source control.

Conclusion: Patients often present with a myriad of symptoms that must be taken into account when considering a differential diagnosis. Patients that are critically ill more often than not are unable to verbalize all their symptoms; therefore, a broad differential diagnosis and thorough work-up must be performed in their evaluation to adequately guide treatment.

  Abstract Number 11 Top

Pediatric Conversion Disorder

Steven Joyce, Natasha Collia1

Department of Emergency Medicine, Summa Health System, 1Department of Emergency Medicine, Akron Children's Hospital, Akron, Ohio, USA

Introduction: Pediatric conversion disorder is a rare condition which typically presents with vague neurological complaints, for which an organic cause cannot be found. Neurological complaints can include mild symptoms such as weakness to profound symptoms such as seizures. While no underlying organic cause of the disease can be found, the disease, nonetheless, can be highly debilitating. Patients presenting to a clinic with new-onset neurological symptoms should have conversion disorder on the differential, particularly when no underlying cause is evident.

Case Study: A 14-year-old female presented to the Emergency Department (ED), with lower extremity weakness, blurred vision, and a recent history of frequent falls. She was an immigrant who moved to the United States 10 years prior. Her last trip to her home country was about 6 months before this ED visit. She was hospitalized shortly after her last travel due to blurred vision and weakness but had spontaneous symptom resolution. No underlying cause was found. On this second presentation, she had blurred vision, extremity weakness, increased frequency of falls, increased sleepiness, headaches, abdominal pain, and decreased appetite. She denied any recent illness, weight or diet changes, seizure-like activity, syncope, head injury, or depression. The patient reported being otherwise healthy before the initial admission. Her blood work was unremarkable. Non-contrast computed tomography of her head and brain was negative. A lumbar puncture was negative for infectious etiology and oligoclonal bands. The patient was admitted to the medicine service for observation and further work-up. Magnetic resonance imaging of the head was negative for demyelination or intracerebral pathology. A psychiatric evaluation with the addition of counseling was initiated. The patient was admitted for 2 weeks; however, no definitive organic pathology was identified. Ultimately, she was discharged home in stable condition with full resolution of her symptoms and instructions to follow-up with psychiatry.

Conclusion: Conversion disorder can be a frustrating diagnosis for clinicians, and most initial laboratory work and imaging is negative resulting in further testing. It is prudent to consider psychological causes, including conversion disorder. Many times, asking about or having a history of comorbid conditions, such as depression, can exacerbate or reveal conversion disorder. In light of a completely negative work-up, it is extremely important to screen for, and treat, underlying comorbidities to ensure a quicker return to health for the patient.

  Abstract Number 12 Top

Inhalational Heroin-induced Transverse Myelitis

Anne Lally, Daniel Keratsoulas, Travis Ulmer

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Heroin abuse is an epidemic with over 914,000 people 12 years or older using heroin in the United States in 2014. Heroin use is associated with side effects such as rhabdomyolysis, infections, immune reactions, myelopathy, and transverse myelitis. While rare, serious reactions within the spinal cord are documented in the literature and often have led to poor outcomes. We report a case of transverse myelitis, following nasal inhalation of synthetic heroin.

Case Study: A 24-year-old male with a previous history of illicit drug abuse was transferred to the Emergency Department (ED) after being found unconscious. The patient had been found hunched over the steering wheel after losing consciousness the previous night when he snorted heroin powder. The patient had an abnormal neurological examination below umbilicus, paralysis of lower extremities, and weakness in upper extremities. Laboratory results in the ED were significant for blood urea nitrogen of 83 mg/dL, serum creatinine of 7.05 mg/dL, creatinine kinase of 68,000 U/L, and transaminitis. Magnetic resonance imaging (MRI) of the head and cervical spine revealed abnormal signals from C1 to C6. The patient was admitted to the intensive care unit for his acute renal failure (ARF) along with deteriorating mental and respiratory status. His neurological deficits were extensive, and he received 5 days of high-dose methylprednisolone. A lumbar puncture was performed and his neurological work-up was negative for cerebral spinal meningitis, neuromyelitis optica, and syphilis. The cerebrospinal fluid analysis demonstrated elevated protein of 247 mg/dL, elevated IgG and myelin basic protein, and elevated angiotensin-converting enzyme level. An extensive infectious and rheumatologic work-up was performed which did not yield any diagnostic results. Throughout his 4 weeks in the hospital, the patient received intermittent hemodialysis, plasmapheresis, and extensive physical and occupational therapy and was discharged to a rehab facility. An exit MRI showed no changes in the lesion, and on physical examination, he had regained minimal fine motor control in his upper extremities with no improvement in his lower extremities.

Conclusion: The combination of rhabdomyolysis, ARF, and transverse myelitis occurring together in a patient has been uncommonly described making this a unique case. In conclusion, heroin exposure can present as a variety of neurological and renal complications that should be considered early in the ED evaluation.

  Abstract Number 13 Top

Brain Metastasis: An Uncertain Outcome

Eric Landman

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Metastatic adenocarcinoma is cancer that has originated in one part of the body, traveled most commonly through the lymphatic pathways, and then seeded into another part of the body. This breaking off of cancerous cells then forms a secondary tumor at the new location that is genetically similar to primary cancer. We present a case report of a patient with generalized symptoms as well as hallucinations and headaches to the Emergency Department (ED), for which diagnostic imaging revealed metastatic cancer.

Case Study: A 71-year-old female presented to the ED with hallucinations and headaches which had been present for 2 weeks. The patient had a medical history of breast cancer 20 years ago which was thought to have been cured by a lumpectomy. Initial laboratory testing was normal except a urinary tract infection caused by Escherichia coli and Klebsiella pneumoniae. A computed tomography scan of the head was ordered due to concern of cranial pathology causing the symptoms and led to a positive finding of metastatic cancer within the brain. After careful discussion with the patient and considering all options, she elected to continue with a brain mass biopsy and debulking for symptomatic relief and further classification of mass etiology. The final pathology results concluded metastatic adenocarcinoma likely secondary to history of breast cancer.

Conclusion: After initial presentation and thorough work-up, the patient who presented with hallucinations and headaches was determined to have a brain mass. Through this case, we are able to demonstrate how cancer begins as a primary tumor and is able to metastasize and form a secondary tumor at another location in the body. We also show the utility and importance of tumor marking in determining the secondary tumor type which can direct our management and knowledge of where the tumor originated as well as going forward with the best type of intervention and treatment. Furthermore, in the ED, taking a complete medical history is very important to guide an appropriate diagnostic work-up to determine the etiology of the patient's symptoms.

  Abstract Number 14 Top

Preserved Right Eye Vision with Central Retinal Artery Because of Unilateral Collateral Arterial Supply

Doug Mayeux, David Custodio

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Central retinal artery occlusion represents a specific type of stroke event manifested as partial or complete loss of vision to the affected side. As with other strokes, these events are managed with initial identification of the etiology of the stroke, with subsequent measures taken to decrease the risk of future events. The most common risk factors for stroke include hypertension, hyperlipidemia, diabetes mellitus, cardiac arrhythmias, most notably atrial fibrillation, and atherosclerosis, most notably in the carotid arteries. Central retinal artery occlusion typically affects patients aged 60–65 years and occurs in 1–10 in 100,000 patients.

Case Study: A 68-year-old male presented to the Emergency Department with a 12-h history of diminished vision in the right eye, most noted in the periphery. He further described his vision as cloudy, with spotty areas of increased acuity. The patient had a history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and atrial fibrillation. The patient was on rivaroxaban. Initial evaluation included a neurological examination to include field of vision testing. Bedsides, ultrasound was then performed, which identified a small posterior defect, concerning for possible retinal detachment. The patient was subsequently evaluated by ophthalmology and found to have central retinal artery occlusion (CRAO), with fovea and central acuity spared, thanks to the presence of cilioretinal artery. Interestingly, the patient only had a cilioretinal artery present on the affected right eye, with the absence of a cilioretinal artery on the left side. The patient was admitted for overnight observation and discharged the next day with scheduled outpatient ophthalmology follow-up. On discharge, the patient's medications, including rivaroxaban, were unchanged except for an increase in amlodipine for better control of hypertension.

Conclusion: CRAO is a form of stroke which occurs rarely. The clinical work-up for acute onset is similar to that used for other strokes including an evaluation for etiology and implementation of preventive measures. Patients can typically be safely discharged following completed evaluation. This patient was fortunate to have collateral flow to the central portion of his right eye and was able to avoid right sided blindness.

  Abstract Number 15 Top

More Than Your Average ST-elevation Myocardial Infarction

Brigid Shields

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Acute pericarditis is a common cause of chest pain and may be commonly mistaken for myocardial infarction. Chest pain may be acute in onset, sharp, and pleuritic in nature. A pericardial friction rub may be heard at the left sternal border. The electrocardiogram (EKG) may show signs of diffuse ST elevation and PR depression, which may sometimes be interpreted as ischemia.

Case Study: A 76-year-old female initially presented to emergency medical services (EMS) stating she did not feel well. The patient had a medical history of hypertension, diabetes mellitus type II, and hyperlipidemia. An EKG performed by the squad showed questionable ST segment changes. The ST-elevation myocardial infarction team was activated by EMS. On arrival in the resuscitation bay, she was found to be hypotensive and in atrial fibrillation with rapid ventricular response. She was cardioverted and again ST elevation was noted. The patient was emergently transferred to the cardiac catherization laboratory which identified chronic stable plaques and no critical lesion that was concerning for an acute myocardial infarction. The patient's laboratories were remarkable for an initial white blood cell of 26,000 mg/dL. A closer look at the EKG after the catherization appeared more consistent of pericarditis. An echo performed the next morning showed a moderate-sized pericardial effusion without right ventricular diastolic collapse. That afternoon, the patient went into cardiac arrest due to pericardial tamponade, an emergent pericardiocentesis was performed, and white purulent fluid was expressed. A drain was left in place. Cardiothoracic surgery became involved for pericardial stripping. Pericardial fluid cultures grew Group B Streptococcus. On talking to the family, the patient had multiple episodes of skin abscesses or cellulitis. Perinfectious disease, intravenous ceftriaxone was started and continued as an outpatient. The patient was discharged to a rehab facility after a 14-day cardiac care unit admission.

Conclusion: Pericarditis can mimic a myocardial infarction. If there is clinical suspicion for a pericardial effusion, it is important to get an early bedside echo for a patient with unstable vitals. Clinicians should “never let the sun set on a pericardial effusion.” – Dr. Joseph Pietrolungo.

  Abstract Number 16 Top

Celiac Artery Aneurysm: A Case Report and Literature Review

Michael Finucan

Department of General Surgery, Summa Health System, Akron, Ohio, USA

Introduction: We present a case of a celiac artery aneurysm incidentally diagnosed and electively repaired.

Case Study: A 48-year-old man was referred to vascular surgery office for the evaluation of a 2cm celiac artery aneurysm found incidentally on a computed tomography scan during a work-up for kidney stones. At surgery, the abdomen was accessed through a supraumbilical midline laparotomy incision. The suprarenal aorta was exposed at the diaphragmatic hiatus after entering the lesser sac. The celiac aneurysm was easily identified, and the branches to splenic, left gastric, common hepatic, and phrenic arteries were dissected out. Vascular clamps were applied to the splenic, left gastric, and phrenic arteries, which were subsequently ligated. At this point, the celiac artery was clamped, and the aneurysm was opened and resected. A 6 mm polytetrafluoroethylene graft was used in the artery reconstruction sewed in an end-to-end fashion.

Conclusion: Celiac artery aneurysms are a rare lesion comprising about 4% of all splanchnic artery aneurysms. The overall incidence is estimated to be between 0.005% and 0.2%. To date, <200 cases have been described in medical literature, with the first successful repair in 1958. A review of cases from 1745 to 1984 noting changes in the associated epidemiological demographics. The most common etiology shifted from infectious to atherosclerosis. Today, most patients present asymptomatically or with vague abdominal symptoms. Notably, the increase in incidence and rate of early detection directly correlates to advancements in radiographic technology. As with other aneurysmal lesions, rupture is the feared complication as it carries with its serious morbidity and mortality risks. Modern case series have shown rupture rates that range from 10% to 20%, with an associated mortality of 50% compared to 5%. Although independent risk factors have not been definitively established, early intervention is almost uniformly endorsed based on the high success rate and safety of elective repair. Indications for surgery are generally based on aggravating factors such as size, thrombosis, and calcification. When looking at the ideal approach, prosthetic graft appears to have a benefit in long-term patency with revascularization. The natural course and intervention of the celiac artery aneurysm in our patient serve to bolster the consensus and expert opinion in an area deficient of large statistical analyses due to its rarity while maintaining the need for a case-by-case approach to determining the most appropriate surgical intervention.

  Abstract Number 17 Top

Carcinoid Tumor in a Meckel's Diverticulum: An Unusual Case

Craig Kornbau

Department of General Surgery, Summa Health System, Akron, Ohio, USA

Introduction: Meckel's diverticulum is the most common congenital abnormality of the bowel occurring in approximately 2% of the population. This remnant of the omphalomesenteric duct often remains asymptomatic, and patients never require intervention. Complications of Meckel's diverticulum include bleeding, obstruction, and infection. These complications occur inversely proportional to age and adult cases of symptomatic Meckel's diverticulum are rare. Neoplasm can arise in a Meckel's diverticulum and is an extremely rare finding, occurring in <1% of all Meckel's diverticula. Carcinoid tumor, a neuroendocrine type neoplasm, is the most common tumor to arise in a Meckel's diverticulum.

Case Study: We present a case of a 39-year-old male with progressively worsening right lower quadrant pain. Initial laboratory work-up revealed a leukocytosis and computed tomography of the abdomen and pelvis revealed a dilated appendix. The surgical service was consulted and the patient was taken to the operating room with a presumptive diagnosis of appendicitis. On operative evaluation, the patient was found to have a grossly normal-appearing appendix, but a thickened and irregular Meckel's diverticulum. Both the diverticulum and the appendix were removed, and the patient was discharged the following day with a final diagnosis of Meckel's diverticulitis. On final pathology, the Meckel's diverticulum was discovered to contain a 4mm carcinoid tumor.

Conclusion: Meckel's diverticulum is rarely symptomatic in adult patients, and neoplasm is an unusual finding. Practicing clinicians should be aware of the pathology related to Meckel's diverticulum, as well as the current literature and recommendations regarding this uncommon disease process.

  Abstract Number 18 Top

Surgical Extraction of a Delayed Symptomatic Polymethylmethacrylate Cement Pulmonary Embolism

Andrew Martin, Sheridan Morgan, Michael Firstenberg

Department of General Surgery, Summa Health System, Akron, Ohio, USA

Introduction: Pulmonary cement embolization (PCE) is a rare but significant complication of vertebroplasty surgery. The management of this process is not well studied and depends on the extent and duration of symptoms.

Case Study: Here is a case of a 68-year-old woman who was found to have symptomatic PCE involving the left main pulmonary artery 9 months after a kyphoplasty surgery performed with polymethylmethacrylate.

Conclusion: She was successfully managed surgically by a left main pulmonary embolectomy with symptomatic resolution postoperatively.

  Abstract Number 19 Top

Perforation of Duodenal Diverticulum Causing Pancreatitis

Melissa Pastoressa

Department of General Surgery, Summa Health System, Akron, Ohio, USA

Introduction: Diverticula are commonly found in the gastrointestinal tract and are frequently located in the sigmoid colon. While it is not unusual to find duodenal diverticula, rarely do they have important clinical manifestations. In some instances, the location of the duodenal diverticulum can irritate surrounding organs, especially in the setting of perforation, and can lead to conditions such as pancreatitis.

Case Study: A 66-year-old male with a history of diverticulosis presented with increasing abdominal pain as his only complaint. His initial laboratories were remarkable for an elevated white blood cell count and elevated lipase. A computed tomography scan of his abdomen and pelvis revealed a duodenal diverticulum. The patient was initially treated conservatively for pancreatitis secondary to duodenal diverticulum with plans for delayed resection once his pancreatitis had resolved. However, despite appropriate antibiotic coverage, his white blood cell count remained elevated. Subsequent scans revealed a perforated duodenal diverticulum complicated by the formation of an abscess. The patient was then taken to the operating room for definitive management where a diverticulectomy was performed.

Conclusion: Perforated duodenal diverticula causing pancreatitis are a rare clinical manifestation. It is reasonable to initially treat this condition conservatively. However, with clinical deterioration or development of complications such as an abscess, patients may require immediate, definite management with surgery as opposed to a delayed resection.

  Abstract Number 20 Top

Rare Rectal Polyp: The Gastrointestinal stromal tumor of it

Justus Philip, Frederick Slezak

Department of General Surgery, Summa Health System, Akron, Ohio, USA

Introduction: Gastrointestinal stromal tumors (GISTs) are spindle cell neoplasms which occur most commonly in the stomach and small intestine with <3% occurring in the rectum and approximately 0.1% of all polyps originating in the rectum.

Case Study: Herein, we report a case of an 86-year-old male who underwent excision of rectal GIST and right liver partial lobectomy for metastasis 5 years ago. Subsequently, he underwent 5 years of Gleevec (imatinib) therapy. One year later, on follow-up examination, the patient was found to have a recurrent polyp in the rectum which, after transanal excision, was found to be recurrent GIST.

Conclusion: Rectal GISTs are rare tumors with a clinical course that is highly variable, depending on its mitotic rate, size, and location. Close clinical follow-up and extended suppressive therapy are critical for disease-free survival.

  Abstract Number 21 Top

Nonbeneficence Protocol to Avoid Patient Harm

Shirley Thomas, Steven Radwany

Department of Hospice and Palliative Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Physicians engage patients or surrogates in critical medical decisions including those surrounding life-sustaining treatment (LST). When surrogate or patient decisions conflict with medical recommendations, a nonbeneficent treatment protocol can offer a pathway to resolution. The objectives were to describe a nonbeneficial treatment protocol which balances patient/family decisional rights with professionals' ethical responsibility to “do no harm” and elucidate this decision-making process in the context of an unfortunate and challenging clinical situation.

Case Study: A 40-year-old intravenous drug user with recurrent endocarditis was admitted postoperatively to the intensive care unit after a tricuspid valve repair. He eventually required maximum ventilator and pressor support, broad-spectrum antibiotics for septic shock, blood products for coagulopathy/heparin-induced thrombocytopenia, continuous venovenous hemodialysis for renal failure, and ultimately extracorporeal membrane oxygenation. He suffered progressive ischemic necrosis of all limbs that would necessitate amputation for survival. Critical care, cardiology, infectious disease, surgery, hematology, and palliative care teams were involved and agreed that this was not a survivable illness. His spouse was 5 months pregnant with their first child and refused withdrawal of any treatment in spite of this extremely poor prognosis. The patient seemed to be left neither dead nor alive on these life-sustaining measures while she struggled with her very complicated grief. Per-hospital protocol, the Ethics Committee was consulted to implement the nonbeneficent treatment protocol. As it was being rolled out for this patient, his spouse agreed to withdrawal of LST and implementation of comfort measures and the patient died shortly thereafter.

Conclusion: Patient autonomy conferred upon a distressed surrogate may place an unrealistic and nearly impossible burden when there are no meaningful alternatives available to the patient. When the clinical situation is grim and the prognosis is clear, medical paternalism might be more helpful for families facing tragedy. Such decisions can be grounded on a medical nonbeneficent treatment protocol, a tool for a sound ethical and legal decision-making process which protects patient and surrogate rights while preserving providers' professional integrity.

  Abstract Number 22 Top

Acute Pancreatitis: It's not Always Alcohol, Even in an Alcoholic

Senyo Agidi, Sideris Facaros, Rex Wilford

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Acute pancreatitis is a common cause of abdominal pain. Most cases are due to gallstones or alcohol abuse. Pancreatic cancer, the fourth-leading cause of cancer death in the USA, rarely can cause acute pancreatitis. Early diagnosis is critical for potential curative treatment with prolonged survival. Here, we present a case of acute pancreatitis secondary to pancreatic cancer.

Case Study: A 56-year-old male with a medical history of chronic hepatitis C, chronic alcohol abuse, and tobacco abuse presented with 3 days epigastric pain radiating to the back, nausea, and anorexia without weight loss. Due to presentation of classic symptoms and lipase levels greater than three times normal, he was diagnosed with acute pancreatitis, thought to be secondary to chronic alcohol use. He was admitted for intravenous fluids, pain management, and further work-up. Laboratory work-up revealed normal triglycerides and calcium levels. Ultrasound (US) of the gallbladder revealed no cholelithiasis or biliary ductal dilation but did suggest a 3.3 cm pancreatic head complex mass. Subsequently, computed tomography (CT), with contrast, confirmed a cystic lesion in the pancreas head with possible superior mesenteric vein involvement, mild pancreatic ductal dilation, and pancreatitis. CT-guided core biopsy revealed a poorly differentiated pancreatic adenocarcinoma. The patient underwent neoadjuvant and multi-agent chemotherapy and subsequently underwent exploratory laparotomy, which showed complete encasement of the superior mesenteric vein and its tributaries by the mass. The tumor was deemed to be unresectable. He is currently receiving palliative chemotherapy with gemcitabine.

Conclusion: Although chronic alcohol use is a common culprit for acute pancreatitis, US is recommended to screen for gallstone pancreatitis. Unfortunately, the pancreas is not well visualized on US due to bowel gas and abdominal fat obstruction. Overall, diagnostic accuracy for pancreatic pathology is 64% for US and 84% for CT. With our patient, we were fortunate that the pancreas head was visualized and the mass was discovered. It is important to consider pancreatic cancer as a cause of acute pancreatitis in patients with no other identified cause, especially in the setting of age >40, weight loss, or with a new onset of diabetes mellitus. Our patient had no other identifiable cause, except chronic alcohol use. If the US had been non-diagnostic, persistent symptoms would have led to further imaging with CT scan. It is important to keep pancreatic cancer as a differential diagnosis for acute pancreatitis even if another potential etiology is present.

  Abstract Number 23 Top

Therapeutic Hypothermia for Out-of-hospital Cardiac Arrest: A Case Report

Elise Brady, Bradley Moore

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Out-of-hospital cardiac arrest (OHCA) affects approximately 326,000 patients annually in the United States. However, advances in post-cardiac arrest care have improved outcomes in selected patients. Among these advances is the use of therapeutic hypothermia (TH) defined as the deliberate reduction in core body temperature to a range of 32°C–34°C in a patient who does not regain consciousness after return of spontaneous circulation (ROSC). A case of OHCA is presented to familiarize clinicians on TH implementation, the evidence supporting its use, and which patients benefit most from TH.

Case Study: A 60-year-old female was brought to the Emergency Department (ED) after her spouse saw her suddenly collapse after she complained of mild chest discomfort. Her spouse called 911 and an operator coached him on how to perform cardiopulmonary resuscitation (CPR) for 10 min before paramedics arrived. The patient was found in ventricular fibrillation at the scene and was defibrillated four times. In addition, she received four doses of epinephrine, sustained 40 min of CPR, and was intubated before ED arrival. In the ED, she achieved ROSC after 7 min of CPR and an EKG was obtained that showed an ST-segment elevation myocardial infarction. The patient was transported to the cardiac catheterization laboratory and was found to have 100% de novo stenosis in the proximal left anterior descending artery (LAD) and 70% stenosis of the mid-LAD. She received three drug-eluting stents and TH protocol was initiated. On hospital day 3, the patient started to open her eyes and follow commands. She was extubated on the hospital day 4 and was able to restart a cardiac diet with thin liquids on the hospital day 5. The patient was then discharged home on hospital day 6. She had no apparent neurologic deficits.

Conclusion: This case highlights the importance of an effective emergency response system and appropriate post-cardiac arrest care, particularly the role of TH. According to the American Heart Association, approximately 12% of OHCA patients survive during hospital discharge. Even though it is well established that TH improves short and long-term mortality risk, TH protocols tend to vary between different institutions. This is felt to be related to the small sample sizes of the initial studies and the absence of well-powered randomized trials. Despite differences in protocols, TH is a rapidly evolving therapy which will likely be better understood as more data become available. It is important for clinicians caring for OHCA patients to understand TH as the potential reduction in morbidity and mortality is significant.

  Abstract Number 24 Top

Insulinoma: A Case of Diagnostic Challenge with 13 Years of Symptoms

Kamal Dayal, Omar Zmeili

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Insulinomas are often a diagnostic and therapeutic challenge and can be associated with significant morbidity. Even after a specific biochemical diagnosis is reached, insulinomas may be radiographically absent and may necessitate invasive testing for localization of the tumor. Correct diagnosis and treatment require a mix of appropriate history taking, biochemical testing, radiological testing, confirmatory invasive testing, and surgical intervention.

Case Study: A 70-year-old female patient presented with symptomatic hypoglycemia requiring D10 drip during an admission for congestive heart failure exacerbation. Further, history revealed that she had been battling symptoms of hypoglycemia for about 13 years, and previous work-up had revealed a normal hemoglobin A1c. A 72 h fast was consistent with a diagnosis of insulinoma. However, a computed tomography (CT) of the abdomen followed by an endoscopic ultrasound was negative for a culprit lesion. Due to high clinical suspicion without radiographic identification, intra-arterial calcium gluconate stimulated venous sampling was performed of the patient's abdominal veins. The results of this study were equivocal and did not further clarify her diagnosis or location of a lesion. The patient had a repeat 72 h fast which again confirmed her diagnosis biochemically, and she was placed on octreotide injections to control her blood sugar. An intraoperative laparoscopic ultrasound of the pancreas was being considered when fortunately, a repeat CT abdomen, this time performed with pancreas protocol, revealed a 1.7 cm × 1.5 cm lesion in body/tail of the pancreas, likely representing a neuroendocrine tumor. The patient underwent laparoscopic enucleation of her islet cells, and pathology was consistent with insulinoma. Currently, she is doing well, and no longer suffers from hypoglycemia.

Conclusion: This unique case of insulinoma illustrates that it is a diagnosis which often involves complexity and variability in identifying and treating. First, symptomatic hypoglycemia can be easily overlooked in a nondiabetic patient presenting with typical symptoms and can be difficult to diagnose. Next, the differential for symptomatic hypoglycemia in a nondiabetic is broad and often requires a monitored fast to work-up. Furthermore, when biochemically diagnosed, noninvasive and invasive tests to locate insulinoma have variable sensitivities and specificities. Finally, providers must be cognizant of multiple endocrine neoplasia syndromes, which may initially present with hypoglycemia secondary to insulinoma.

  Abstract Number 25 Top

Linitis Plastica: A Rare Cause of Presenting Gastric Outlet Obstruction and Stomach Cancer

Sideris Facaros, Leah Giaccotto, Howard Zhang

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Linitis plastica is a diffuse infiltrative type of stomach adenocarcinoma. It involves extensive mucosal erosion and a thickened gastric wall, giving it the nickname of “leather bottle stomach.” It is a rare cause of stomach cancer, accounting for 3%–19% of gastric adenocarcinomas. Patients typically do not develop symptoms until the disease is more advanced, resulting in gastric outlet obstruction.

Case Study: An 80-year-old Caucasian female presented with symptoms of early satiety, nausea, vomiting, and weight loss. She had been suffering from worsening symptoms for roughly 1 year and stated that she had unintentional weight loss of 50 pounds over that time span. Initial management was done as an outpatient and included computed tomography (CT) scan and upper endoscopy. CT scan of the abdomen showed a possible abdominal mass and a resulting upper endoscopy showed whole food in the stomach and esophagus, prompting the patient to present for inpatient care for further work-up. While hospitalized, a nasogastric tube was placed for gastric decompression which yielded 5 L of stomach food contents during her stay. Upper endoscopy was repeated inpatient and showed diffuse firm, nodular, and ulcerated mucosa with poor compliance in the stomach as well as severe duodenal stenosis. Stomach biopsies demonstrated signet ring cell adenocarcinoma compatible with linitis plastica. Secondary to poor prognosis and her advanced age, the patient declined surgery or chemotherapy and palliative care was consulted. To maintain quality of life, pleasure feeds were continued, a venting gastrostomy was placed, and the patient was discharged home.

Conclusion: This case highlights the importance of considering linitis plastica when a patient presents with gastric outlet obstruction. Because of the limited sensory qualities of the stomach, linitis plastica is typically advanced once a patient develops symptoms. Although prognosis is poor, chemotherapy with and without radical surgery has been proposed. Complete resection is usually not available due to the late onset and dissemination to the surrounding tissues. Peer-reviewed literature and ongoing research have differed in survival rates but overall, the prognosis remains poor. Once a diagnosis of linitis plastica is made, a multidisciplinary team approach between the patient/family along with oncology and surgeon specialists should be made that align with the patient wishes.

  Abstract Number 26 Top

Hemosuccus Pancreaticus: A Rare and Obscure Cause of Gastrointestinal Bleed

Sideris Facaros, Yesha Patel, Howard Zhang

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Hemosuccus pancreaticus is a rare cause of obscure gastrointestinal (GI) bleeding. Blood enters the GI tract through the duodenal ampulla of Vater, most commonly secondary to erosion or rupture of a splenic artery pseudoaneurysm.

Case Study: A 56-year-old hemodynamically stable Caucasian male with a medical history significant for alcoholism and multiple episodes of pancreatitis complicated by pseudocyst formation presented with a 1-week history of worsening epigastric abdominal pain, nausea, emesis, melena, and hematochezia. The triad of elevated lipase, area of pain, and medical history directed initial medical management toward the treatment of acute pancreatitis. The patient's abdominal pain responded to therapy; however, initial hemoglobin of 11.5 plummeted to 8.7 within 2 days. Per-chart review, baseline hemoglobin had been 15. An evaluation for an upper GI bleed was initiated with an upper endoscopy. The procedure revealed deposition of fresh blood within the second portion of the duodenum beyond the ampulla and no other GI bleeding source such as inflammation, ulcer, or mass lesion. The finding of fresh blood in the second portion of the duodenum raised suspicion for hemosuccus pancreaticus, especially with the patient's history. Subsequently, mesenteric angiogram confirmed the presence of a tortuous splenic artery with a 1.9 cm pseudoaneurysm in the midportion, which was immediately treated via transcatheter arterial embolization. The patient's bloody bowel movements subsequently resolved. He remained hemodynamically stable with stable H/H. Shortly thereafter, he noted new onset of left-sided abdominal pain which was attributed to splenic infarction suggested by hypoattenuation of the spleen seen on computed tomography abdomen. Before discharge, the patient was prophylactically vaccinated with meningococcal and Haemophilus B vaccines and was scheduled for outpatient follow-up.

Conclusion: This case displays an obscure source of GI bleed in the setting of pancreatic pseudocyst from alcoholic pancreatitis, along with the complication of splenic infarction from embolization. It emphasizes that the rare differential of hemosuccus pancreaticus should always be considered if risk factors are present. Our patient was fortunate to have objective findings present that led to an immediate diagnosis. Due to the sporadic nature of bleeding, diagnostic findings may not always be visualized; however, it is imperative that evaluation of a GI bleed be continued because a delayed diagnosis may be life-threatening.

  Abstract Number 27 Top

Invasive Pulmonary Aspergillosis Following Influenza

Susanna Mathias, Shanu Agarwal1

Departments of Internal Medicine and 1Infectious Diseases, Summa Health System, Akron, Ohio, USA

Introduction: Here, we present an uncommon case of invasive pulmonary aspergillosis (IPA) in an immunocompetent patient, following a severe infection with influenza.

Case Study: A 60-year-old immunocompetent Caucasian female presented to an outside hospital with dyspnea and fatigue. She developed respiratory failure and was subsequently intubated. Chest X-ray revealed multifocal pneumonia. The patient was found to be lymphopenic and in acute renal failure. She was empirically started on ceftriaxone, piperacillin/tazobactam, azithromycin, and oseltamivir. Rapid influenza test was positive for influenza A. Within 24 h of admission, the patient became hypotensive and required vasopressors. Endotracheal aspirate was sent for culture and was positive for Streptococcus pneumoniae and Aspergillus fumigatus. The Aspergillus initially was thought to be nonpathogenic; however, despite treatment for pneumococcal pneumonia and influenza, the patient was slow to improve. A few days after admission, a computed tomography (CT) chest was done which revealed nodular infiltrates concerning for Aspergillus. The diagnosis was further supported by a highly positive Aspergillus galactomannan test (index 8.65). Antifungal therapy with voriconazole was added to her regimen. After completing a course of therapy for pneumococcal pneumonia and influenza A, the patient was maintained on voriconazole for 6 months. She had clinical improvement and subsequent CT scans showed resolution of the previously noted nodular infiltrates.

Conclusion: IPA typically occurs in immunocompromised hosts. However, in the past decade, there have been more cases reported in immunocompetent hosts with influenza A. H1N1 has notably been a more severe strain of influenza. Literature review showed 57 reports of postinfluenza IPA since 1979. More than half of them occurred after 2010 and 40 were attributed to H1N1. Lymphopenia was a common laboratory finding in most of these patients. Patients who developed IPA also tended to be more critical, needing vasopressors and organ support, like dialysis. Bronchoscopy culture, sputum culture, and galactomannan assay were all commonly used diagnostic tools. Seventy percent of the 57 cases were attributed to A.fumigatus, as with our patient. Unfortunately, mortality in the 57 cases was high at 46%. The Infectious Disease Society of America guidelines for the treatment of IPA recommend voriconazole to be used as the first-line treatment.

  Abstract Number 28 Top

Primary Peritonitis due to Streptococcus pyogenes: Report of Two Cases and Review of the 21st Century Literature

Yesha Patel, Bahar Moftakhar, Jose Poblete, Joseph Myers

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Primary peritonitis (PP) is peritonitis occurring in patients without underlying causes such as perforated viscus, preexisting ascites, or nephrosis. We report two patients with PP due to Streptococcus pyogenes (SP) and review all patients reported in the literature in the 21st century.

Case Series: Case 1: A 45-year-old woman was seen in the Emergency Department (ED) with fever, diarrhea, and abdominal pain. Abdominal examination showed fever, hypotension, and epigastric tenderness and guarding. Abdominal computed tomography (CT) scan showed nonspecific small bowel changes. Cultures were obtained, antibiotics were begun, and she was referred to the surgical service, who performed an exploratory laparotomy which revealed peritonitis, exudative fluid without luminal perforation. Preoperative blood cultures revealed SP. Postoperative recovery on ceftriaxone was rapid and unremarkable. Case 2: A 47-year-old woman was seen in the ED with fever, anorexia, nausea, vomiting, and abdominal pain. Examination revealed fever, hypotension, tachycardia, and abdominal tenderness without rebound. Abdominal CT scan revealed free fluid. Abdominal paracentesis showed purulent fluid. Blood cultures from admission revealed SP. Surgery was consulted and they proceeded rapidly to exploratory laparotomy which revealed purulent fluid and interloop abscesses without luminal perforation. Postoperatively, she had a prolonged recovery requiring penicillin G, hemodialysis, and ventilator support. She recovered without long-term sequelae.

Conclusion: Since January 1, 2000, 36 patients with PP due to group A streptococci (GAS) were reported in the literature. With our two patients, there were 38 patients. Despite each report stating that PP due to GAS is a “rare” disease, it appears that it may be more common than originally thought and almost all patients required surgical intervention. Of the 38 patients, 32 were women ranging in age from 17 to 60, with a mean age of 36 years. All of the 38 patients presented with physical findings of an acute abdomen. There was no evidence of free air on X-ray, CT imaging or ultrasound of the abdomen in any of the 33 patients who underwent any of these imaging techniques. Of the 38 patients, 31 presented with or developed septic shock. Thirty-five of the 38 underwent surgical intervention: 23 laparoscopy alone; 7 laparoscopy and then laparotomy. One patient underwent paracentesis and two patients had no intervention. Thirty-seven of the 38 of patients survived. GAS-PP in patients is more common than previously reported, is associated with examination findings of acute abdomen and circulatory shock, shows no radiographic evidence of abdominal free air, is clinically responsive to operative and antimicrobial treatment, and has a low mortality rate.

  Abstract Number 29 Top

The Intrinsic Relationship between Malaria and the Kidneys

Neil Rangwani, Sideris Facaros, Tushar Chaturvedi1, Rupesh Raina2, Shanu Agarwal, Robert Novak2

Department of Internal Medicine, Summa Health System, 1Akron Nephrology, 2Department of Pathology and Laboratory Medicine, Akron Children's Hospital, Akron, Ohio, USA

Introduction: Malaria is thought of as a disease of the tropics. Without many cases found in the U.S., the severity of the disease and rapid progression can have hazardous effects on various organs. There have been few reports highlighting the relationship between malarial infections and severe kidney dysfunction that require long-term hemodialysis (HD).

Case Study: A 53-year-old African-American woman who recently returned from Sierra Leone, Africa, presented with dizziness, nausea, and extreme fatigue. She felt progressively worse over a period of 1 week with increased thirst and decreased urine output. There was no previous medical history or surgeries before this presentation. Initial laboratories showed an elevated blood urea nitrogen and creatinine, which increased throughout her hospital stay despite intravenous fluid resuscitation. Laboratory work was significant for anemia among other aberrations. She was coherent at presentation but became steadily confused and encephalopathic, coinciding with worsening kidney function. Her urine examination revealed nephrotic range proteinuria and physical examination was pertinent for generalized jaundice, scleral icterus, and mildly distended abdomen with right upper quadrant tenderness. With her travel history, physical examination, and pertinent laboratory findings, a peripheral smear showed Plasmodium falciparum with significant parasitemia and she was diagnosed with a severe malarial infection. She required a temporary vascular catheter placement and HD initiation with uremic symptoms and worsening acute kidney injury. A renal biopsy demonstrated podocytopathy consistent with minimal change disease. A permanent vascular catheter was placed due to worsening renal function and the patient was discharged on outpatient HD once the infection was treated and other abnormalities normalized.

Conclusion: This case highlights the significance between severe malarial infections and severe kidney disease that requires long-term HD. Only a few reports on minimal change disease as a result of malarial infections are known. The postulate is that falciparum has a molecular mimicry of podocytes causing antigen-antibody reaction, emphasizing the importance of quickly identifying a P. falciparum malarial infection because of the devastating effects it can have on the body.

  Abstract Number 30 Top

The Fall that Started it All: Disseminated Gonococcal Infection, Rheumatoid Arthritis, and Lupus Diagnosed from Mechanical Fall

Kaitlyn Sheppard, Jacqueline Kannan, Ron Jones

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Obtaining a sexual history cannot be undervalued, especially for disseminated gonococcal infection. Furthermore, remembering that patients with rheumatologic diseases are at higher risk for these infections is important to guide work-up.

Case Study: A 28-year-old female presented to the Emergency Department with a chief complaint of left knee pain and swelling after a mechanical fall. Examination was positive for left knee pain and swelling without erythema or warmth. An X-ray showed a large joint effusion and no fracture. Her complete blood count, basic metabolic panel, and urinalysis were within normal limits. Pregnancy test was negative. Orthopedics was consulted with concern for patellar tendon disruption. Arthrocentesis was performed, and she was placed in a brace. Discharge home was anticipated, but her temperature increased to 100.9°F with tachycardia at 98 bpm. She admitted to a wound on her right leg for 3 weeks, and further examination revealed a 2 cm purulent ulceration on the right calf. Blood and urine cultures were obtained, intravenous ampicillin/sulbactam and vancomycin were begun, and she was admitted to the hospital for sepsis secondary to wound infection versus septic joint. Joint fluid showed 51,250 nucleated cells, 93% neutrophils, negative crystals, and negative Gram stain. Joint fluid culture and blood cultures had no growth. Orthopedics was concerned for inflammatory arthritis. Further history obtained revealed morning stiffness in both ankles and hands for 2 years, and further examination revealed nodules on her elbows and deformities of her fingers. She also admitted to high-risk sexual activity with multiple partners. A urine chlamydia and gonorrhea test was obtained and rheumatoid arthritis work-up was pursued. Rheumatoid factor was elevated at 970, cyclic citrullinated peptide at 195, anti-nuclear antibody at 1:2560, and dsDNA at 1:80. She was diagnosed with rheumatoid arthritis and potentially lupus. The plan was for discharge home on a prednisone taper and rheumatology follow-up; however, urine gonorrhea and chlamydia testing was positive and joint fluid grew rare  Neisseria More Details gonorrhoeae. She was diagnosed with disseminated gonococcal infection and treated with azithromycin and ceftriaxone. She was discharged home on oral cefixime and a follow-up with rheumatology.

Conclusion: This case illustrates the importance of obtaining a sexual history in all patients. It also demonstrates that patients with rheumatologic disorders are more prone to septic arthritis, so further work-up based on history should be obtained. Finally, it demonstrates the importance of recognizing heuristic errors, specifically anchoring heuristic and premature closure in this case, to promote patient care and safety.

  Abstract Number 31 Top

Linear IgA Bullous Dermatosis: A Rare Blistering Rash Associated with a Common Antibiotic

Christopher Tanayan, Bernole Batenga, Bradley Moore, Jose Danguilan, Carleo Capili

Department of Internal Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Linear IgA bullous dermatosis (LABD) is a rare skin disorder with a clinical presentation similar to many other blistering cutaneous diseases. This often makes the diagnosis difficult or inaccurate. A case is presented to familiarize clinicians with this disease.

Case Study: A 58-year-old female developed a vesicular rash after antibiotic treatment for bacteremia from bilateral lower extremity venous stasis ulcers with cellulitis. It was limited to the C8 dermatome and initially thought to be from herpes zoster. She was discharged to a nursing facility where valacyclovir, ceftriaxone, and vancomycin were continued. The rash became vesiculobullous, spreading to her mouth, trunk, and extremities, raising concern for  Stevens-Johnson syndrome More Details and prompting transfer back to the hospital. Her medical history included obesity, atrial fibrillation, remote unprovoked pulmonary embolism and deep vein thrombosis, hypertension, osteoarthritis, and venous insufficiency. She had no known drug allergies. Other medications included amiodarone, rivaroxaban, carvedilol, Lisinopril, acetaminophen, oxycodone, and furosemide. On physical examination, she had normal vital signs and was not in distress. There were small erythematous ulcers on her lips and underneath her tongue. Erythematous vesicles and bullae developed on her neck, trunk, and extremities as well. Due to concern for a drug-induced rash, valacyclovir, ceftriaxone, and vancomycin were shifted to acyclovir, levofloxacin, and daptomycin. Polymerase chain reaction for herpes simplex virus and varicella from the vesicular fluid was negative and acyclovir was discontinued. Skin biopsy demonstrated linear bands of IgA and IgG along the basement membrane zone consistent with LABD. The skin lesions slowly resolved a few days after discontinuation of the antibiotics and treatment with topical steroids.

Conclusion: LABD is a rare, autoimmune blistering disease that may be drug-induced or idiopathic. It presents with subepidermal vesiculobullous mucocutaneous lesions and is differentiated from other similar conditions through skin biopsy and direct immunofluorescence microscopy showing linear IgA deposits along the basement membrane. Most drug-induced LABD cases have been documented with vancomycin and its withdrawal is usually sufficient for recovery. Therapy with steroids and dapsone is recommended for the idiopathic type. This case is presented to increase awareness of LABD and its association with vancomycin, a commonly used antibiotic. Earlier suspicion may lead to prompt diagnosis, appropriate management, and improved patient outcomes.

  Abstract Number 32 Top

Candida glabrata Infection after Descemet Stripping Automated Endothelial Keratoplasty in Two Patients from a Single Donor

Alisha Gandhi, Marc Jones1

Department of Ophthalmology, Summa Health System, 1Department of Ophthalmology, Northeast Ohio Eye Surgeons, Akron, Ohio, USA

Introduction: Descemet stripping automated endothelial keratoplasty (DSAEK) is a partial thickness corneal transplant performed to treat corneal pathologies including Fuchs' dystrophy. Donor tissue is processed, preserved, and sent to physicians in storage media by many eye banks across the country. Microbial keratitis secondary to contaminated donor tissue is an uncommon but serious complication of corneal transplant that renders a poor prognosis. This case report describes Candida glabrata infection after DSAEK in two patients who received corneal grafts from the same donor.

Case Series: Patient #1 was an 87-year-old male and patient #2 was a 71-year-old female. Both had Fuchs' dystrophy with extensive corneal edema and preoperative best corrected visual acuity (BCVA) of count fingers (CFs) at three feet in their right eyes. They underwent DSAEK by the same surgeon on the same day. Both donor corneas were from a single donor. One week postoperatively, patient #1's corneoscleral rim culture was positive for Group A beta-hemolytic streptococci and yeast. The postoperative course was unremarkable for both patients at their 1 day, 1 week, and 1 month visits. At their 2-month postoperative visit, both patients had signs of intraocular infection; patient #1 had six discrete infiltrates at the graft interface and patient #2 had a single infiltrate on the endothelium. Patient #1 improved on oral and topical voriconazole and achieved BCVA of 20/20 at his 6-month postoperative visit. Patient #2 was treated on topical and oral voriconazole; however, she remained to have latent infection. Culture of her anterior chamber aqueous fluid was positive for C. glabrata, and she opted for a more aggressive treatment course with 10 injections of voriconazole in the anterior chamber and three injections of amphotericin intrastromally over the course of 1 month. She achieved resolution of infection with 3-year postoperative BCVA of 20/30.

Conclusion: There are 17 documented cases of fungal keratitis after DSAEK. Hundred percent of them required removal of the endothelial graft and 76% of these required therapeutic penetrating keratoplasty to eradicate infection. These cases are unique examples in which nonsurgical management led to control of infection, maintenance of initial graft, and excellent visual acuity outcome. These cases emphasize keeping fungal keratitis high on the differential for infection after DSAEK, the importance of culturing corneoscleral rim tissue, and the need for future research to evaluate the safety and efficacy of adding antifungal agents to storage media.

  Abstract Number 33 Top

Fall into Darkness: A Case of Ocular and Orbital Ischemia

Krupa Patel

Department of Ophthalmology, Summa Health System, Akron, Ohio, USA

Introduction: We present a unique case of ocular and orbital ischemia in association with ophthalmoplegia likely due to trauma. With this history in a young individual, we must have a high index of suspicion for carotid artery dissection. A review of the literature shows that neuro-ophthalmic complications of dissection can include ocular ischemic syndrome, central retinal artery occlusion, ischemic optic neuropathy, and/or amaurosis fugax.

Case Study: A 41-year-old Caucasian male presented with complete sudden-onset vision loss for duration of 1 day. The patient was unaccompanied and stated that he was inebriated before his shift. He denied any trauma; however, he was found prone on the floor and did not remember any actions preceding this event. Ophthalmic review was positive for swelling around right eye (OD) and discharge both eyes (OU). The patient had no medical history or prior medication use. However, his social history was significant for alcohol and heroin abuse. On examination, the patient was found to be no light perception OD and 20/30-2 left eye (OS). His pupil OD showed minimal reaction with an afferent pupillary defect while OS was within normal limits. He was found to have restricted extraocular movements and no confrontation visual field on the right side. Slit lamp exam demonstrated 3+ upper lid edema with 360° of diffuse chemosis and injection. The patient was found to have stromal edema OU with a large epithelial defect OS. The posterior examination OD demonstrated diffusely pale retina with intraretinal hemorrhage and a central area of retinal striae as well as disc edema. Computed tomography (CT) head was unremarkable. This patient was thus admitted to rule out neuro-ophthalmic emergency. On day 1 of admission, the patient underwent a CT angiogram which showed no evidence of aneurysm or dissection and magnetic resonance imaging was negative. The patient was discharged and lost to follow-up.

Conclusion: This patient likely developed ocular and orbital ischemia due to traumatic compression from his prone position for an unknown length of time. However, the purpose of this case is to demonstrate the necessity to rule out life-threatening neuro-ophthalmic emergencies in situ ations where the examination findings may not fit a specific diagnosis. Although there was no dissection ultimately found, as demonstrated in the literature, this is a unique case in which we would need to broaden our differential and look urgently for any life-threatening conditions.

  Abstract Number 34 Top

An Unusual Presentation of Neurotrophic Keratitis from Crack Cocaine

Payal Shah

Department of Ophthalmology, Summa Health System, Akron, Ohio, USA

Introduction: Neurotrophic keratitis, a corneal disease due to impaired trigeminal nerve function, can result in epithelial defects, corneal ulcers, and perforations. Common causes include diabetes mellitus, herpes, and surgical trauma. A seldom reported cause is cocaine use. Although the pathogenesis of cocaine-induced neurotrophic keratitis is unknown, theories include: (1) a direct toxic effect from smoke resulting in epithelial cell changes, (2) decreased corneal sensation from a local anesthetic effect resulting in decreased blinking and exposure keratopathy, (3) neurotrophic changes from corneal nerve damage, and (4) mechanical trauma from smoke resulting in ocular irritation. These factors combined likely result in “crack eye syndrome.” As an estimated 1.5 million people in the United States use cocaine, broadening our understanding of, and accurately diagnosing, cocaine's adverse effects is paramount. We report an unusual cause of bilateral neurotrophic keratitis secondary to crack cocaine use.

Case Study: A 51-year-old African-American female with congestive heart failure, coronary artery disease, hypertension, and polysubstance abuse presented to the Emergency Room with dyspnea and a 6-day history of bilateral eye pain, irritation, watery discharge, decreased vision, and foreign body sensation. Ophthalmology was consulted for bacterial conjunctivitis. She denied a history of diabetes, trauma, head or neck surgery, herpes, or sick contacts. Examination revealed poor visual acuity, diffuse injection, and large central corneal epithelial defects bilaterally. She was diagnosed with neurotrophic keratitis from crack cocaine after admitting to cocaine use 1 day before symptom onset. A bandage contact lens and ciprofloxacin drops were used in the right eye. A pressure patch was placed over the left eye. By the day of discharge, symptoms had resolved, vision was 20/25, and epithelial defects had resolved. The patient has not presented for outpatient follow-up.

Conclusion: For patients with an unusual presentation of bilateral keratitis, careful attention must be paid to drug use. Cocaine has detrimental effects on various organs, including the eye. Well-known ocular complications include orbital inflammation and central retinal artery occlusion. A lesser known complication of cocaine is “crack eye syndrome,” a form of neurotrophic keratitis, which can lead to corneal epithelial defects, ulcers, and decreased vision. Consider aggressive therapy for these patients as many are likely to delay care. Patients with neurotrophic keratitis should have frequent ophthalmic assessments.

  Abstract Number 35 Top

Carotid Artery Aneurysms: Unusual Cases of Neck Pain

Jennifer Haas, Joseph McShannic

Department of Vascular Surgery, Summa Health System, Akron, Ohio, USA

Introduction: Carotid artery aneurysms are a very rare entity. They occur in <1% of all arterial aneurysms. The male to female ratio is about 2:1 with an average age of about 53. Infection, trauma, and atherosclerosis are among the top causes for the formation of carotid artery aneurysms. Usual work-up includes carotid duplex ultrasound and computed tomography (CT) with 3D reconstruction. They can often be mistaken for other neck masses or abscesses making the diagnosis more challenging. Patients commonly present with neck pain, a pulsatile mass, and dysphasia.

Case Series: The first patient is a 71-year-old female with history of atrial fibrillation, syncope, hypertension, and gastric ulcers who presented to the vascular surgeon's office with neck pain that radiated to her shoulders. A CT angiogram (CTA) of her neck showed a 2.3 cm saccular aneurysm of her left proximal internal carotid artery. The second patient is a 27-year-old male with a medical history significant only for depression and migraines. On presentation to the vascular surgeon's office, the patient complained of neck pain and headaches despite being seen and worked up by neurology. He did have a CTA which demonstrated at 1.3 cm saccular right-sided internal carotid artery aneurysm. The final patient is a 79-year-old male with a medical history of a transient ischemic attack (TIA), hyperlipidemia, and reflux who presented with symptoms of dizziness and neck pain. In his work-up for stroke and dizziness, a magnetic resonance angiography of his neck was ordered which illustrated a 1.2 cm saccular right-sided internal carotid artery aneurysm. All of these patients were taken to the operating room and underwent resection of the aneurysm with bovine patch angioplasty. All patients did well after the procedure and were discharged from the hospital on postoperative day 1. On follow-up in office, all three patients had improved neck pain with no residual aneurysmal disease.

Conclusion: Treatment of carotid artery aneurysms is crucial to reduce the risk of TIA, amaurosis fugax, stroke, and death. The stroke rate varies from 50% to 70% with mortality as high as 71% making early diagnosis and treatment of carotid artery aneurysms imperative. Options for surgical reconstruction include venous graft and bovine patch angioplasty (which was used in these cases). The presence of saccular artery aneurysms, regardless of size, warrants repair due to complications of embolization and rupture. Overall, open surgical repair of extracranial carotid artery aneurysms is a safe approach with good long-term outcomes.

  Abstract Number 36 Top

Cerebral Air Embolus: A Rare Complication of Endoscopy

Charles Schall, Michael Osmundson

Department of Emergency Medicine, Summa Health System, Akron, Ohio, USA

Introduction: Air embolus after upper endoscopy (UE) is an extremely rare event with few recorded cases. In order for an air embolus to occur, there must be a direct communication of the source of air and the vasculature as well as a pressure gradient favoring the passage of air into the circulation rather than bleeding from the vessel. While virtually all organ systems are susceptible to ischemia induced damage secondary to systemic emboli, the cerebrovascular system is particularly vulnerable and may lead to neurological symptoms. We present a case where the patient had an air emboli with neurological symptoms following an UE.

Case Study: A 29-year-old female arrived in the Emergency Department (ED) as a prehospital stroke team. The patient had an UE for esophageal stricture dilation that morning and returned home. In the afternoon, she had developed a left sided facial droop and left sided weakness. The patient's NIH stroke scale was 9 upon ED arrival. Crepitus was appreciated on the right neck. Her vitals were stable. A non-contrast computed tomography (CT) of the head was negative for any acute process. A CT angiogram of the head and neck showed subcutaneous air in the neck, pharynx and mediastinum but no acute arterial occlusion. The CT of the thorax with contrast showed subcutaneous emphysema in the peripheral and deep neck soft tissues, mediastinum, intraperitoneal tissues and retroperitoneum. It also showed marked portal venous gas probably arising from gastric and/or esophageal veins consistent with possible esophageal perforation. The patient was discussed with cardiothoracic surgery at another facility and was transferred for an esophagram and possible hyperbaric treatment, which she subsequently underwent. Further imaging revealed findings that suggested a miniscule perforation and possible air emboli in the right parietal lobe. During her hospital course, the patient developed generalized seizures and was started on antiepileptics. The patient was discharged ten days after her transfer. Upon discharge, the patient's neurologic symptoms had resolved.

Conclusions: Though an extremely rare complication, air embolus should be considered in all patients with neurologic deficits after an endoscopy especially due to the treatment variation from a cerebral infarct secondary to a thrombogenic process. Together with cardiopulmonary resuscitation if the patient is hemodynamically unstable, it is currently recommended to place the patient in Trendelenburg and left lateral decubitus position and to give adequate oxygen or hyperbaric oxygenation therapy as soon as possible.


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