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  Cutaneous Leishmaniasis in a Traveler: A Case Report

  Sarah Al-Obaydi MD, Nemer Dabage MD, and James DeMaio MD

  Leishmaniasis, a vector-borne infection transmitted by sandflies, is endemic throughout the Mediterranean basin and the tropics. We present a case diagnosed in Florida after overseas travel.

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  Pasteurella Multocida Bacteremia Secondary to Multiple Cat Scratches

  Charles Boadu MD, Andrea Hernandez MD, Bassem Zeidan MD, John T. Young MD, and Johnathan Frunzi MD

  Pasteurella multocida(P. multocida)is part of the normal gastrointestinal and upper respiratory flora of domestic and wild animals such as dogs, cats, rabbits, opossums, boars, tigers, lions and horses ^{(1, 2)}. Transmission of P. multocidais usually through scratches and bites leading to infections of the soft tissue and skin ^(3,4). P. multocida bacteremia is rare, but occurs in individuals with major risk factors including chronic pulmonary disease, diabetes mellitus, end state renal disease (ESRD), and an immunocompromised state ^(3,4). Non traumatic infections of P. multocida in immunocompromised individuals,are more likely to require care in the intensive care unit (ICU), likely to occur in patients with severe comorbidities, and are likely to end in mortality ⁽⁴⁾. In this case, we present P. multocida bacteremia in an immunocompromised adult male with end stage kidney on hemodialysis.

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  What is Scannable? An MRI Safety Guide

  Michael Burcescu MD, Ravi Patel MD, Robert Hessemer DO, Peter Lore DO, Sriharsha Kota DO, and Guarav Kumar MD

  Supernumerary MRI protocols and recommendations exist to guide physicians at the forefront of patient care. While urgent imaging may be necessary for critical patients, inadvertent imaging of implantable devices can incur serious morbidity and mortality[11]. The American College of Radiology published a 30-page manual in 2013[1] on MRI safe practices and releases yearly updates with critical information separately[2]. There is increased utilization of advanced imaging modalities, especially among academic institutions[3]. Physicians are hard pressed to maximize efficiency; uncertainty delays imaging. Moreover, inappropriate orders delay appropriate management. We present pertinent and often questioned considerations in a comprehensible format along with devices that may have ferromagnetic material such as iron, cobalt, or nickel.

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  Pneumonia: An Unexpected Graveyard Visitor?

  Daniel A. Casas DO, Jigar Chauhan MD, Melanie Williams DO, Jan Sambataro MD, David Sukhai MD, Pablo G. Dubon MD, and Jorge Perez MD

  Community acquired pneumonia caused by Influenza can present with superinfection. On rare occasions, an unexpected organism is discovered.

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  Bedside Point of Care Ultrasound Diagnosing Bilateral Valve Involvement in Infective Endocarditis

  Corey Cole DO, Alfredo Tirado MD, and Jonathan Schwadron DO

  Endocarditis is a well known complication of intravenous drug abuse which classically affects the tricuspid valve. It is usually diagnosed by formal echocardiogram and positive blood cultures. Vegetations involving both the mitral and tricuspid valves are rare, occurring in less than 5% of all cases of infective endocarditis. 1 Here we report a case of a patient with vegetations on both valves which was discovered by point of care ultrasound.

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  A Rare Case of Primary Cutaneous Mucoepidermoid Carcinoma

  Hassie Cooper DO, Maheera Farsi DO, Richard Miller DO, Pay Kamrani, and Dudith Pierre Victor

  Mucoepidermoid carcinoma (MEC) is a well-documented malignant tumor commonly found in the salivary glands. Cutaneous involvement is very rare, especially when presenting as a primary cutaneous neoplasm. Gallagher first described primary cutaneous MEC in 1959 and since then, to the best of our knowledge, there have been approximately 20 reports published in the literature. Here we present a very rare case of primary cutaneous mucoepidermoid carcinoma.

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  New Onset Psychosis Secondary to Neurosyphilis

  Lauren Angela DeMarco DO, Samantha Linda Jane Vu DO, Francis Butler MD, and Nihal Shah MD

  Syphilis is a highly contagious sexually transmitted infection (STI) caused by the spirochetal bacterium Treponema pallidum. Transmission occurs through direct contact of painless ulcerative lesions, chancres, located on the genitalia (penis, labia) and oral mucosa. Neurosyphilis is any involvement of the central nervous systems (brain, meninges, or spinal cord) by the bacterium.

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  The Difficult Airway: Developing a Consistent Approach

  Catherine Divingian MD, Tammy Ferro DO, and Dudith Pierre-Victor PhD

  The primary objectives were to determine the best practices in managing difficult airways (DAs) and to generate a simplified algorithm for a consistent approach. Additional objectives included organizing a DA cart, and integrating the information into the electronic medical record (EMR).

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  Cervical Cancer Recurrence in the Colon

  Samantha A. Erb DO, Shreyash Pandya MD, and Johnny Johnson MD

  Cervical cancer is the fourth leading cancer worldwide in women, ranking only after breast cancer, colorectal cancer, and lung cancer. Because it is typically diagnosed at a younger age compared to other major cancer types, it leads to a proportionally greater loss in life-years. Most cancers occur in squamo-columnar junction, the transition point between squamous and columnar cells; squamous cell carcinoma accounts for approximately 70% of cervical cancer cases. Treatment options vary depending on the stage at diagnosis and include surgery (conization or hysterectomy), radiation, chemotherapy, targeted therapy, and immunotherapy. Prognosis is affected by stage, tumor volume, age and performance status, and treatment type.

  Local recurrence of cervical cancer is not uncommon. It is known to metastasize to distance sites including the lung, liver, bone, and supraclavicular lymph nodes, with rare cases involving the breast, paraspinal muscles and duodenum. Metastatic spread of cancer from extracolonic origin to the colon is uncommon. It occurs very rarely in breast and lung carcinomas (~2%), as well as stomach, prostate, breast, ovarian and melanoma This is a care case of a recurrence of cervical cancer that spread to the colon and presented as a sigmoid lesion.

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  Carcinoid Syndrome Arising from the Descending Colon causing Carcinoid Heart Disease

  Julien A. Exposito DO, Adam Salomon DO, Oliver Fowler DO, Christopher Cooke DO, Joelle Ellis MBBS, Patricia Chun DO, and Christiano Caldeira MD

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  An Atypical Presentation of Neuroleptic Malignant Syndrome

  Rudy Forte MD, Shiwani Kamath MD, Debra Angelo MD, and Johnathan Frunzi MD

  Neuroleptic Malignant Syndrome (NMS) is a rare, but potentially life threatening condition associated with dopamine blockade, particularly first-generation antipsychotics. The complex pathophysiology of NMS remains somewhat unclear and debatable as the symptoms are not fully explained by dopamine blockade alone.¹ D2 dopamine receptor antagonism remains responsible for most cases of NMS, however a few cases have been reported in which little to no D2 blockade activity was present.¹

  This poster is about an atypical presentation of NMS.

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  A Rare Case of Trichilemmal Carcinoma: Histology and Management

  Lisa F. Fronek DO, Allyson Brahs, Maheera Farsi DO, and Richard Miller DO

  Trichilemmal carcinoma (TC) is a rare, malignant, adnexal neoplasm that is derived from the outer root sheath (ORS) of the hair follicle. These tumors predominantly occur in elderly patients on sun-exposed areas, specifically on the head and neck with the face defined as the most common location. The mean age of diagnosis is 70 years old with a slight male predominance. These lesions are commonly identified as a papular, nodular, and sometimes, exophytic. They generally arise de-novo, but may also derivate from an underlying proliferating trichilemmal cyst with a loss of p53, a seborrheic keratosis, a nevus sebaceous, or a scar. They can be locally aggressive and may exhibit telangiectasias and ulceration due to local destruction.

  While the clinical differential diagnosis commonly includes basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and keratoacanthoma, the histopathological differential also includes trichilemmoma, trichoepithelioma, clear cell SCC, clear cell porocarcinoma, and clear cell hidradenocarcinoma. The main differentiating histological feature in a TC is the evidence of trichilemmal keratinization, where the tumor exhibits an absence of granular layer between the stratum spinosum and stratum corneum. The standard of treatment for TC is wide local excision (WLE) with tumor free margins, however, there has been increasing evidence for the efficacy of Mohs micrographic surgery (MMS) in recent years.

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  Corpus Cavernosum Abscess Secondary to Traumatic Perforation of Urethral Diverticulum

  Thomas C. Gore DO, Anna Schepcoff DO, and Domenick Sorresso MD

  A corpus cavernosum abscess is a rare condition. Usual etiologies include penile injection of erectile dysfunction medications or illicit drugs, priapism, sexually transmitted infections, and trauma; however, there have been reported cases of idiopathic etiology. The most common causative organisms include Staphylococcus aureus, Streptococci, and Bacteroides [1]. Diagnosis is typically made clinically and through imaging (computed tomography [CT] and ultrasound). The first-line treatment is the use of intravenous (IV) antibiotics and surgical drainage. More conservative treatment, however, includes aspiration in conjunction with IV antibiotics [2-3]. Urethral diverticulum (UD) is the formation of a saccular outpouching of the urethral lumen. Symptoms may include recurrent urinary tract infections, incontinence, hematuria, and dysuria [4]. We present a unique case of a corpus cavernosum abscess secondary to perforation of a UD through self-catheterization.

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  Acral Lentiginous Melanoma: A Rare Variant with Unique Diagnostic Challenges

  Taylor Gray DO, Brett Brazen, Maheera Farsi DO, and Richard Miller DO

  Acral lentiginous melanoma (ALM), named for its location and histological growth pattern, is a rare variant of melanoma. ALM presents on palms, soles, or in association with the nail unit.1 While ALM accounts for approximately 5% of melanomas diagnosed each year, it is the most commonly diagnosed subtype of melanoma in non-Caucasian patients.

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  The Evil Twin: The Case of Heterotopic Pregnancy

  Rashmi Jadhav MD, Vegas Brown MD, and Gabriel Cabrera MD

  • Heterotopic pregnancy occurs in about 1 in 30,000 naturally conceived pregnancies (5). The risk rises 1-3% for pregnancies occurring through assisted reproductive technologies (ART) (1).
  • Isolated ectopic pregnancy affects an average of 1 in every 150 live births (1).
  • A known pre-existing intrauterine pregnancy (IUP) can be falsely reassuring and delay the diagnosis of a potentially life-threatening concurrent ectopic pregnancy.
  • Presentation is vague and 45% of patients have no symptoms (5).
  • Differential Diagnoses: endometritis, incomplete miscarriage, ruptured ovarian cyst, non-GYN cause (ie: appendicitis or UTI).
  • Risk Factors: Infertility treatment, in vitro fertilization (IVF), prior ectopic, prior tubal surgery, use of IUD, smoking (1).
  • These patients are more likely to have spontaneous or medically induced abortions, and are 30% less likely to have live-birth delivery.
  • Laparoscopy or laparotomy are standard of care. They carry a 58-70% success rate of parturition for the IUP (1).

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  Idiopathic Chylopericardium: A Rare Entity

  Seema Jaga MD, Joseph Namey DO, Christiano Caldeira MD, and Salah Al-Andary MD

  • Idiopathic chylopericardiumis a rare entity in which the acculumation of chylousfluid surrounds the pericardial space.
  • Herein, we present a case of a 50 year old healthy female patient with no known past medical history that was diagnosed with idiopathic chylopericardiumand was successfully treated using a pleurXcatheter drainage for two and a half weeks and a low fat diet.

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  Teriparatide and its Bone Healing Power

  Aneeta Joseph, Jesus L. Penabad MD, and Antonio Pinero-Pilona

  Teriparatide, a parathyroid hormone analog, is an important anabolic agent approved by the U.S. Food and Drug Administration to increase bone mineral density in osteoporotic patients. Parathyroid hormone (PTH) regulates calcium, phosphate, and active vitamin-D metabolites. The amino terminal peptide fragments of PTH has been known to increase bone mass and are being used in clinical practice for osteoporosis management.3 Teriparatide increases bone density of lumbar spine and femoral neck, and decreases the risk of vertebral and non-vertebral fractures both in postmenopausal women and men. It is also known to prevent fractures in patients with osteoporosis and promote healing of fractures.

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  Novel Infection Status Post Electrocution Requiring a 4th Ray Amputation

  William R. Judson IV, DO; John D. Murphy DO, MBA; Phillip H. Sussman DO; and John N. Harker DO

  • Prevotella bivia is an anaerobic, non-pigmented, Gram-negative bacillus species that is known to inhabit the human female vaginal tract and oral flora. It is most commonly associated with endometritis and pelvic inflammatory disease.^{1, 2}
  • Rarely, P. bivia has been found in the nail bed, chest wall, intervertebral discs, and hip and knee joints.¹ The bacteria has been linked to necrotizing fasciitis, osteomyelitis, or septic arthritis.^{3, 4}
  • Only 3 other reports have described P. bivia infections in the upper extremity with one patient requiring amputation2, and one with deep soft tissue infection requiring multiple debridements and extensive tenosynovectomy.⁵
  • Delays in diagnosis are common due to P. bivia’s long incubation period and association with aerobic organisms that more commonly cause soft tissue infections leading to inappropriate antibiotic coverage.
  • Here we present a case on P. bivia that resulted in extensive tenosynovectomy, multiple irrigations and debridements and eventually amputation of the 4th ray and digit of the hand.

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  Fracture Blisters

  Jessica Khabra MD, Jinal K. Patel MD, Gauthier L. Stepman MD, Kulveer Dabb MD, Kenny Hernandez MD, Debra Angelo MD, and Johnathan Frunzi MD

  Fracture blisters are tense vesicles or bullae that develop on edematous skin following some acute long bone fractures. Fracture blisters are infrequently seen, as the reported incidence is 2.9% to 6.6%.¹ This rare complication, may not regularly be encountered by Physicians in the hospital. Fracture blisters typically occur within 24-48 hours following high energy trauma injuries & may last up to several weeks. Ultimately, this condition can lead to prolonged hospital stay due to an increased risk of infection and delay in surgical intervention.² Early recognition of this dermatologic complication may be helpful in reducing hospital stays.

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  Vitamin D Deficiency and Perceived Pain

  Theodore Korty DO, Adam Grunbaum DO, Ken Baxa DO, and Olu Oyesanmi

  Vitamin D deficiency has been shown to contribute to the onset of musculoskeletal pain, headaches, and fatigue (1, 2). Deficient levels of calcium phosphate have been linked to musculoskeletal pain associated with vitamin D deficiency (3). Low levels of calcium phosphate may result in an inadequately mineralized bone matrix, and normalization of vitamin D levels should help to diminish symptoms of pain by correcting suboptimal mineralization of bone matrix (3). One prior study of patients who underwent orthopedic procedures (including treatment of vertebral compression fractures, Colle’s fractures, hip & knee arthroplasty, ligament repair, and meniscal repair), showed that 44% (n = 272) had evidence of vitamin D insufficiency (20-32 ng/mL) or deficiency (< 20 ng/mL) (4).

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  End the Glow!

  Roli Kushwaha MD, Anthony Furiato DO, and Justin McNamee DO

  Aortic dissection (AD) is part of a group of acute aortic syndromes consisting of intramural aortic hematoma, penetrating aortic ulcer, and aortic rupture. On its own, the incidence is ~3 to 8 cases per 100,000 per year, and up to 25% of cases are missed. The in-hospital mortality when treated is 27%, and with a 2% increase in mortality/hour. Imaging modalities like CT angiography, TEE, and MRA have made improved diagnosis of the disease, but are costly, potentially harmful, time consuming, and require patient stability when in use (1). The key question we have as emergency department providers is if there is a way to risk stratify patients for AD and if so, is there a test with high enough sensitivity and negative likelihood ratio (-LR) to rule out aortic dissection. Smooth muscle myosin heavy chain is a proposed modality, which is released from injured aortic media at the start of AD but there is a lack of observational studies testing its efficacy as biomarker in making the diagnosis (2). Hence, algorithms to aid physician in reducing both misdiagnosis and overtestingis much needed.

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  Evaluating Awareness of Low-Dose Computerized Tomography For Lung Cancer Screening

  Roshni LeBoutillier DO, Bansi Savla MD, Vincent Wu DO, Zia Khan DO, Erick Mejia DO, Leah Tehranchi DO, My Myers MD, Khine Min MD, Jennifer Broyles MD, and Stacy Chase DO

  In the U.S., excluding melanoma, lung cancer is the leading cause of cancer-related deaths.¹
  Cigarette smoking is the number one risk factor and is linked to 80-90% of lung cancer deaths.²
  Low-dose Computerized Tomography has been shown to reduce lung cancer deaths by 20% in randomized control trials and observational studies.⁴
  The U.S. Preventative Task Force recommends annual screening for lung cancer with low-dose computerized tomography (LDCT) in adults ages 55-80 years of age who:

  • Have a 30 pack-year smoking history and
  • Currently smoke or
  • Have quit within the past 15 years.

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  Bilateral Sporotrichoid Cutaneous Atypical Mycobacterial Infection Due to Primary Inoculation

  Erin Lowe DO, Alexa Broderick, and Richard Miller DO

  The group of mycobacterial species that excludes Mycobacteria tuberculosis and Mycobacteria leprae is known as nontuberculosis or atypical mycobacteria. Nearly all atypical mycobacteria species can cause cutaneous infection. The diagnosis is challenging as disease may take months to become clinically apparent, morphology is non-specific, routine culture has a low sensitivity, and organisms can be sparse on histopathologic examination. Antibiotic resistance and further complicates management. The Gulf Coast is the highest incidence region of cutaneous atypical mycobacterial infections. Here we present a challenging case of bilateral sporotrichoid atypical mycobacterial infection due to primary inoculation.

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  A Case of Medication-Induced Diffuse Alveolar Hemorrhage in Neurofibromatosis Type 1

  Ashar Mahmood MD, Liz Palmer MD, Rebecca Schuyler MD, Svitlana Sharpovalova MD, Bilal Nadeem MD, Mukesh Mehta MD, Salman Muddassir MD, Nikolay Mitzov MD, and Monicka S. Felix MD

  • Amiodarone, an antiarrhythmic and apixaban, an anticoagulant have been associated with diffuse alveolar hemorrhage (DAH).
  • Cases have been documented demonstrating DAH in the setting of amiodarone and apixabantreatment, however there are few cases examining DAH in combination therapy.
  • We present a case of diffuse alveolar hemorrhage in the setting of amiodarone and apixaban treatment for paroxysmal atrial fibrillation.
  • NF1 is know to have higher risk for major bleeds due to their friable vasculature.

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  Iatrogenic Pneumothorax with Subsequent Subcutaneous Emphysema

  George Michael, Eric Yuschak DO, and My Myers MD

  Lung cancer is the leading cause of cancer-related death in the United States, accounting for 13% of all new cancer diagnoses and 24% of all cancer deaths.1 Transthoracic CT-guided biopsy (CTGB) is commonly used as a diagnostic tool for lung cancer, with high diagnostic accuracy, sensitivity, and specificity. 2 This procedure, however, is not without its risks which include pulmonary hemorrhage and iatrogenic pneumothorax (IPNX). Emergent chest tube placement is standard care of treatment for massive or symptomatic IPNX, commonly with the use of smaller caliber chest tubes. 2 There is, however, a growing discussion over use of larger caliber chest tubes in select patients who may pose a greater risk of developing subcutaneous emphysema (SE).5 We discuss a case of a patient with underling lung mass who underwent GTGB and developed IPNX with subsequent SE.

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  Hailey-Hailey Disease Successfully Treated with Low-Dose Naltrexone

  John Moesch DO and Richard Miller DO

  Hailey-Hailey disease (HHD) is an uncommon autosomal dominant disorder resulting from a mutation in the ATP2C1 gene resulting in dysfunction of the Golgi apparatus calcium-associated ATPase, thus interfering with intercellular calcium signaling.

  HHD presents clinically as flaccid blisters and erosions in intertriginous areas, especially the axillae and groin.

  The major histologic finding is acantholysis throughout the spinous layer of the epidermis, commonly referred to as a “dilapidated brick wall” appearance.

  The initial lesions and associated symptoms usually develop during the second or third decade of life.

  Complications of HHD include infections (bacterial, fungal, and viral), and malignant transformation (cutaneous squamous cell carcinoma).

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  Bilateral Posterior Fracture-Dislocation of the Proximal Humerus After First-Time Seizure

  John D. Murphy DO, MBA; Phillip Braunlich DO; and Mohit Bansal MD

  Fractures of the proximal humerus are commonly associated with osteoporosis and comprise 5.7% of all adult fractures [1]. Posterior dislocations of the shoulder comprise 2-5% of all shoulder dislocations, and when bilateral are even more infrequent, occurring less than 5%. [2,3]. Posterior dislocations are often associated with motor vehicle accidents, seizures, or electrical shock [4]. Fracture-dislocations of the proximal humerus occur in only 1% of all shoulder dislocations, thus making posterior fracture-dislocations off the proximal humerus exceedingly rare [5]. In this case report, we present a previously undescribed case presentation and treatment for bilateral posterior fracture-dislocations of the proximal humerus [7,8,9,10,11,12,13,14,15]. The purpose of sharing this case is to describe treatment options for a rarely encountered orthopedic trauma presentation, as there is currently a lack of existing medical literature.

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  Impact of Order Set Use on Stroke Care

  Bilal Nadeem MD, Edward Waseleski DO, Meryem Maras-Casey MD, Sabih Alam MD, Adnan Faruqui MD, Michael Gutierrez MD, Maruthsakhi Molugu MD, Christina Oricompil MD, Ashar Mahmood MD, Katherine Torralba MD, Fatima Agha MD, Nour Tlimat MD, Olu Oyesanmi, Irina Davis, Salman Muddassir MD, and Nikolay Mitzov MD

  • A case control study on stroke patients was recently completed for a quality improvement (QI) investigation.
  • The objective was to determine if the use of either Hemorrhagic or Ischemic Stroke Order Set had an effect on the length of stay (LOS) or adherence to current stroke guideline recommendations

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  Impact of Order Set Use on Stroke Care

  Bilal Nadeem MD, Edward Waseleski DO, Meryem Maras-Casey MD, Sabih Alam MD, Adnan Faruqui MD, Michael Gutierrez MD, Maruthsakhi Molugu MD, Christina Oricompil MD, Ashar Mahmood MD, Katherine Torralba MD, Fatima Agha MD, Nour Tlimat MD, Olu Oyesanmi, Salman Muddassir MD, and Nikolay Mitzov MD

  A case control study of 118 patients from Oak Hill Hospital between the months of August 2019 and January 2020 was recently completed for a hospital research quality improvement study. The objective was to determine if the use of either Hemorrhagic or Ischemic Stroke Order Set had an effect on the length of stay (LOS) or adherence to current stroke guideline recommendations when compared to its disuse. Results indicate use of either the Hemorrhagic or Ischemic Stroke Order Set led to a decreased length of stay and an increased adherence to current stroke guideline recommendations. Limitations of the study included non-adherence to the current 2019 stroke guidelines defined by The American Stroke Association .

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  Acute Hypoxic Respiratory Failure Due To Organizing Pneumonia With Lipoid/Cholesterol Component Caused By THC Vaping With E-Cigarette

  Jinal K. Patel MD, Kiran Tirumalasetty MD, Jessica Khabra MD, Imran Khan MD, and Johnathan Frunzi MD

  Vaping has been the new and deemed “safer” way to inhale addictive chemicals such as nicotine and tetrahydrocannabinol (THC), but it does not encompass the detrimental effects of other ingredients in these vaping cartridges that can cause lung injury[1,2]. Similar studies with dabbing (heating THC wax concentrate at high temperatures with butane) showcase rapidly progressing lung injury with massive consolidation and lasting effects on lung parenchyma over a period of time [3]. This case report aims to educate people, especially the younger generation, of the dangers of newer ways of combustible alternatives that have been marketed as a “safer” way to ingest addictive compounds. Here, we report a case of a patient with THC vaping with Electric-Cigarette causing Organizing Pneumonia with Lipoid Component.

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  A Case of Pott's Disease: Typical Presentation of an Uncommon Disease in the United States

  Neha Patel MD, Ravi Patel MD, Marek Krysztofiak MD, and K V. Sundaresh MD

  Pott’s disease (PD), also known as tuberculosis spondylitis, is a rare disease of the spine which is typically caused by extraspinal infection. The basic lesion in Pott's disease is a combination of osteomyelitis and arthritis, usually affecting more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is commonly involved. Spinal TB can include any of the following: progressive bone destruction leading to vertebral collapse and kyphosis, cold abscess formation (due to extension of infection into adjacent ligaments and soft tissues), spinal canal narrowing by abscesses, granulation tissue or direct dural invasionresulting in spinal cord compression and neurologic deficits.(1) Although the incidence of PD has recently increased in Europe and the United States, mainly due to immigration and an epidemic of acquired immune deficiency syndrome, it is still a rare disease. Here we present a patient who immigrated from India a few months ago who presented to the emergency room with mid back pain and was found to have Pott’s disease confirmed by biopsy and PCR testing.

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  Effect of an Electronic Order Set on Newborn Hepatitis B Immunization Rates

  Daniel Pedersen, Angelina Rodriguez, Michael King, and Heather Schramm

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  Internal Hernia as a Late Complication of Roux-en-Y Gastric Bypass Procedure

  Samantha Purton OMSIII, Gabriel Meshekow DO MPH, My Myers MD, Edgar Mercado MD, and Allan Katz MD

  As the prevalence of obesity continues to rise, so does the popularity of bariatric surgery. Previously the Roux-en-Y gastric bypass was the most common bariatric procedure, but now falls second to the gastric sleeve. It remains a relevant procedure, however, accounting for 17% of bariatric procedures in 2018. Due to its prevalence, it is important that the radiologist be familiar with the procedure and its complications such as leak, obstruction, stricture, or, as in this case, internal herniation through a mesenteric defect. Internal hernias are more commonly associated with the laparoscopic approach versus open. This is likely due to fewer adhesions created to secure the bowel, allowing more freedom for herniation and potential volvulus formation. It is imperative that the surgeon close all mesenteric defects created during the procedure to decrease the risk of this dire complication.

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  Giant Splenic Artery Pseudoaneurysm Rupture Presenting as Hemorrhagic Shock

  Jaya Sanapati MD, Parth R. Desai MD, Locke W. Barber DO, Johnathan Frunzi, and Timothy Lee MD

  A 56-year-old Asian male was brought to the emergency department by first responders after he developed severe, sudden-onset headache and chest pain at his home. Past medical history was insignificant. On arrival to the emergency department, the patient was in respiratory distress. Vital signs revealed temperature of 36.0°C, blood pressure of 71/44, heart rate of 90 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% with delivery of oxygen at 2 liters per minute via nasal cannula. Examination of the abdomen revealed diffuse tenderness. Laboratory findings and arterial blood gas analysis revealed normocytic anemia (hemoglobin 7.6 mg/dL) and an anion gap metabolic acidosis with low arterial pH (7.260) and elevated lactic acid (11.0 mg/dL).

  Computed Tomography (CT) of the abdomen and pelvis revealed a splenic artery pseudoaneurysm, with cross-sectional area of 5.8 x 5.6 cm, and intra-abdominal fluid collections consistent with hemoperitoneum. The patient received transfusion of packed red blood cells and resuscitation with intravenous crystalloids. He subsequently underwent selective splenic artery arteriogram and coil embolization with resolution of pseudoaneurysm filling and extravasation. The following day, exploratory laparotomy with hematoma evacuation and intra-abdominal washout was performed. The patient was given the Haemophilus influenzae type B, pneumococcal, and meningococcal vaccines and discharged.

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  Evolving de Winter Presentation of Acute Myocardial Infarction

  Caroline Shepherd and Anthony Furiato

  de Winter ECG pattern first detailed in 2008 in a case series Diagnostic criteria

  • Tall, prominent, symmetric T waves in the precordial leads
  • Upsloping ST segment depression >1mm at the J-point in the precordial leads
  • Absence of ST elevation in the precordial leads
  • ST segment elevation (0.5mm-1mm) in aVR

  Strongly correlated with acute LAD occlusion

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  Progressive Dyspnea after use of Electronic Vaping

  Taylor Studsrud, Morgan Zegers, Gary Cook, Narrani Kanapathippillai, and Hilton Alemar-Hernandez

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  A Case Of Babesiosis Seen Outside Of Its Endemic Area And Outside Of Its Incubation Period

  Kiran Tirumalasetty MD, Jinal K. Patel MD, Gauthier L. Stepman MD, Bassem Zeidan MD, K V. Sundaresh MD, Parth R. Desai MD, and Johnathan Frunzi MD

  Babesiosis Microti is a parasitic alveolate that is usually transmitted by Ixodes scapularis ticks. In the United States, the endemic areas of Babesiosis include the Northeast and Upper Midwestern regions [1]. Symptoms include fever, malaise, fatigue, vomiting, and jaundice [1]. Current therapy primarily consists of a combination of azithromycin and atovaquone. Clindamycin and quinine may be administered in severe cases. For its emerging health risk worldwide, clinicians must be aware of the several presenting manifestations of babesiosis. Since 2017, the Centers Disease Control and Prevention (CDC) has deemed Babesiosis is a reportable disease. This case focuses on the importance of recognizing Babesiosis outside of its endemic area, and that was past the average incubation period associated of 1-9+ weeks.

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  Segmental Neurofibromatosis: Isolated Eruption of Neurofibromas on the Scapula in a Middle-Aged Man

  Christopher White DO, Brett Brazen, and Richard Miller DO

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  Malignant Degeneration of Spiradenoma of the Eyebrow

  Christopher White DO, Kristin Witfill DO, and Richard Miller DO

  Spiradenocarcinoma is a malignancy of eccrine origin, with only 120 reported cases in the literature.¹ Elderly males and females are equally affected.² Benign spiradenomas along with their malignant counterpart are more frequent in patients with Brooke-Spiegler syndrome or familial eccrine spiradenoma, owing to the increased incidence of folliculosebaceous-apocrine tumors seen with these entities.³

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  A Rare Cause of Pneumoperitoneum

  Robert Zusman DO, George Michael DO, Anna E. Augustin DO, My Myers MD, and Dudith Pierre-Victor

  Pneumoperitoneum is most commonly associated with a perforated viscus. When free air is seen on imaging, the most common course of action is an emergent exploratory laparotomy. However, pneumoperitoneum may not always be indicative of a perforated bowel. In the case described below, we will discuss a patient who developed acute peritonitis and pneumoperitoneum after undergoing chest compressions during cardiopulmonary resuscitation (CPR) and positive pressure mechanical ventilation.