2017 Resarch Forum

17 th ANNUAL RESEARCH FORUM

May 4, 2017

SUMMARY OF ABSTRACTS

KERN MEDICAL Conference Room 1058 and A-Wing 1700 Mount Vernon Avenue Bakersfield, CA 93306

Introduction

Welcome to the 17th Annual Kern Medical Research Forum.

The purpose of the Kern Medical Research Forum is to foster in-depth comprehension of research and to promote scholarly pursuits among residents, faculty, physicians, medical students, nurses, pharmacists, physical therapists, and mental health clinicians for the advancement of medical science. The Forum serves to highlight research activities of Kern Medical and associated staff, and recognize special contributions and innovations. Research and scholarly activity are inclusive requirements of all approved residency-training medical programs at Kern Medical and for Rio Bravo Family Medicine. The importance and value of medical and scientific research is linked to improvement and advancement of patient care. Prior to this evening, we received excellent abstracts representative of the majority of the specialties. The abstracts were blind-scored; the top four scoring abstracts were chosen for the oral presentation competition. A research-experienced jury panel will score the presentations. We would like to acknowledge the hard work of all the participants, faculty and staff. The achievements reflected in the posters displayed represent resident commitment to scholarly activities.

Russell Judd, MS Chief Executive Officer Ruby A. Skinner, MD, FACS, FCCP, FCCM Chair, Institutional Review Board Royce H. Johnson, MD, FACP Director of Research

2017 Research Forum Agenda Thursday, May 4, 2017 Opening Remarks and Poster Viewing • Ruby Skinner, MD, FACS, FCCP, FCCM, Chair, Institutional Review Board • Russell Judd, MS, CEO, Kern Medical Excellence in Research Presenters • Elliott Asarch, PharmD, Department of Pharmacy Services • Tigran Karamanukyan, MD, Department of Surgery • Nadia Moghim, PharmD, Department of Pharmacy Services • Alice Peng, PharmD, Department of Pharmacy Services Excellence in Research Judges • Everardo Cobos, MD, FACP, Chair, Department of Medicine, Chief, Division of Hematology & Oncology • Shahab Hillyer, MD, Department of Surgery, Division of Urology • Garth Olango, MD, PhD, Department of Psychiatry, Program Director, Child and Adolescent Psychiatry Fellowship Program Andrea Pakula, MD, MPH, FACS, Department of Surgery, Associate Director Surgical ICU, Division of Trauma and Acute Care Surgery & Division of Minimally Invasive and Bariatric Surgery Genetics of Cocci: Will Genetics Make a Difference in the Care of Future Patients? Royce Johnson, MD, FACP, Department of Medicine, Chief, Division of Infectious Disease Faculty Research Introducing Robotics into General Surgery Training

5:30 pm

6:15 pm

7:00 pm

7:25 pm

Judging Panel Results and Awards

Certificate of Accomplishment, Outstanding Case Study Abstract Presented by: Ruby Skinner, MD, FACS, FCCP, FCCM, Chair, Institutional Review Board

Table of Contents DEPARTMENT OF EMERGENCY MEDICINE Acute myocardial infarction with simultaneous gastric perforation Alon Kaplan MD 1 , Dan Schwarzfuchs MD 1 , Vladimir Zeldetz MD 1 , Jing Liu MD 2 1 Soroka University Medical Center 2 Kern Medical

C-1

Avulsion of the lesser trochanter following a shot put sport session Mohamed Habib Grissa MD 1, 2 , Nasri Bzeouich MD 1, 2 , Makrim Zrig MD 2 , Hamdi Boubaker MD 1, 2 , Mohamed Amine Msolli MD 1, 2 , Abderrazak Abid MD 2 , Semir Nouira MD 1, 2 , Amanda Montgomery MD, Kern Medical 1 University of Monastir, Dept. of Emergency Medicine 2 Fattouma Bourguiba University Hospital C-2

DEPARTMENT OF MEDICINE

BMI as a predictor of 90 day readmission in heart failure patients with reduced ejection fraction Ali Ammar MD, Jeffrey Coleman MS IV, Saman Ratnayake MD M-1

16042

Discharge hypertension as a predictor of 90 day readmission in heart failure patients with reduced ejection fraction Ali Ammar MD, Jeffrey Coleman MS IV, Saman Ratnayake MD

M-2

16042

Coccidioidomycosis disseminated to the mastoid bone Ali Ammar MD, Greti Petersen MD, Caitlyn Duffin MD, Arash Heidari MD

C-1

15008

Bell’s palsy: presenting with hemiparesis Aarushi Parekh MD, Ahana Sandhu MD, Greti Petersen MD

C-2

16056

Diffuse alveolar hemorrhage and rituximab Aarushi Parekh MD, Ralph Garcia-Pacheco MD

16060

C-3

Severe aplastic anemia as a complication of autoimmune hyperthyroidism Rajinderpal S Chahal MD, Shelly Gupta MD, Arash Heidari MD Rare presentation of metastatic prostate cancer leading to cranial nerve palsies and paranasal sinus masses Shelly Gupta MD, Arash Heidari MD, Edward Williams MS IV, Taylor Barrett MS III A Case of rapidly progressive frontotemporal dementia triggered by life stressors Ali Ammar MD, Kasey Carling MS IV, Jeffrey Coleman MS IV, Saman Ratnayake MD A case of syndrome of inappropriate antidiuretic hormone secretion (SIADH)induced by disseminated central nervous system (CNS) coccidioidomycosis Ali Ammar MD, Arash Heidari MD, Taylor Barrett MS III, Saman Ratnayake MD Extrapulmonary tuberculosis presenting as a painful testicular mass Benson Lee DO, Shahab Hillyer MD, Bethany Ann Citerella MS IV, Arash Heidari MD

C-4

17002

C-5

17003

C-6

17015

C-7

17016

C-8

17026

Extraosseous Ewing’s Sarcoma presented as a scrotal mass Samiollah Gholam MD, A Scott Ragland DO

17030

C-9

A case of asymptomatic Charcot Marie Tooth syndrome with hypersensitivity to vincristine Samiollah Gholam MD, A Scott Ragland DO, Benson Lee DO A rare case of downhill esophageal varices in the absence of superior vena cava obstruction Samiollah Gholam MD 1 , Sehem Ghazala MD 2 , Bupesh Pokhral MD 3 , Archita Desai MD 3 1 Department of Medicine, Kern Medical 2 Department of Medicine, Banner University Medical Center 3 Division of Gastroenterology, Department of Medicine, Banner University Medical Center

C-10

17031

C-11

DEPARTMENT OF OBSTETRICS & GYNECOLOGY Phyllodes tumor of the vulva: a case report and review of the literature Sherryann Taylor-Santos MD, Nathan Abdelsayed MS IV, Sally Nalesnik MD

C-1

DEPARTMENT OF PHARMACY SERVICES

Impact of education on insulin infusion protocol compliance Alice Peng PharmD, Jeffrey Jolliff PharmD, David Lash PharmD Quality outcomes of a pharmacist-led safety-net diabetes clinic Elliott Asarch PharmD, Jeff Jolliff PharmD The Impact of a Meds-to-Bed program on the 30-day readmission rates Nadia Moghim PharmD, David Lash PharmD, Jeffrey Jolliff PharmD, Jeremiah Joson PharmD

M-1

16048

M-2

17010

M-3

17017

DEPARTMENT OF PSYCHIATRY

Examining an inpatient psychiatric unit: The prognostic value of age, gender, race, substance abuse, diagnosis, and antipsychotic treatment on the length of stay and its legal ramifications, a pilot study Samantha Madziarski MD MBA, Sabina Bera MD MS, Kelsey Stevens MD, Matt Cupp MS III, Aida Fran MS III, Kristine Galang RN MS IV, Christopher Spates MS III, Fi Lo MPH MS IV, Kong Davis MS III, Sara Abdijadid DO MS M-1 Religious delusions and hallucinations: Classification, etiology, and effect on the length of stay on the inpatient unit: A Pilot Study Sabina Bera MD MS, Maranda Stokes MS III, Kelsey Stevens MD, Jason Anderson MS IV, Bianca Puello MS III, Sarah Samuels MS IV, Sara Abdidajid DO MS M-2 Preserved coronary distensibility index is associated with reduced adulthood posttraumatic stress disorder in youth with adverse childhood experience Naser Ahmadi MD PhD 1,2,3 , Fereshteh Hajsadeghi MD 1 , Garth Olango MD PhD 1 , Mohammed Molla MD 1 1 Kern Medical 2 Greater Los Angeles VA 3 Los Angeles Biomedical Research Institute M-3

17001

17001

Losing control: A rare presentation of behavioral variant of frontotemporal dementia Sabina Bera MD MS, Naila Mania MD, Mohammed Molla MD A case of galactorrhea associated with citalopram in a Hispanic American woman Sarayu Vasan MD MPH, Kelsey Stevens MD, Sara Abdijadid DO MS A probable case of cycloid psychosis Sarayu Vasan MD MPH, Bruce Fox MD JD, Kelsey Stevens MD, Sara Abdijadid DO MS Application of a geriatric Injury protocol demonstrates high survival rates in elderly trauma patients with high injury acuity Tigran Karamanukyan MD, Andrea Pakula MD MPH FACS, Aswitha Francis MSIII, Maureen Martin MD FACS, Ruby Skinner MD FACS FCCP FCCM Acute care surgery in populations with obesity: Does bariatric/minimally invasive surgical training impact outcomes? Kyle Ota MD, Ruby Skinner MD FACS FCCP FCCM, Maureen Martin MD FACS, Andrea Pakula MD MPH FACS Negative pressure wound therapy for open abdomen treatment: Analysis of outcomes and factors affecting fascial closure Geoffrey C Darby MD, Avneet Nijjar MS III, Andrea Pakula MD MPH FACS, Ruby Skinner MD FACS FCCP FCCM, Maureen Martin MD FACS Timely access to primary surgery, adjuvant chemotherapy and radiation therapy for breast cancer in a public hospital setting is dependent on payer source Margaret Mariella MD, Anna Arakelyan MS III, Heather Hess RN, Maureen Martin MD FACS High-risk injury patterns in Tier II Trauma activations: An analysis of under-triage at a Level II Trauma Center Sergey Kozyr MD, Santa Ponce MS RN, Hope Feramisco RN, Andrea Pakula MD MPH FACS, Ruby Skinner MD FACS FCCP FCCM Early experience with the application of indocyanine green fluorescence imaging for biliary anatomy identification at a teaching institution Jorge Almodovar MD, Ruby Skinner MD FACS FCCP FCCM, Maureen Martin MD FACS, Andrea Pakula MD MPH FACS A Review of Our First 74 Robotic-Assisted General Surgery Cases Domenech Asbun MD, Ruby Skinner MD FACS FCCP FCCM, Andrea Pakula MD MPH FACS A Preliminary Analysis of Risk Factors Associated with Fatal Collisions in Arizona Margaret Li MS II 1 , Mark Fischione MD 1 , Ruby Skinner MD FACS FCCP FCCM 2 1 University of Arizona College of Medicine- Phoenix 2 Kern Medical , Department of Surgery DEPARTMENT OF SURGERY

16033

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16040

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16050

M-1

15026

M-2

16008

M-3

16031

16032

M-4

M-5

16037

M-6

16039

M-7

17019

M-8

RIO BRAVO FAMILY MEDICINE CLINICA SIERRA VISTA

Posterior myocardial infarction: the blind spot in the heart Tana Parker MD, Verna Marquez MD, Corinne Verghese MS III Time is kidney: Clear cell renal cell carcinoma (CCRCC) incidental finding that evaded detection for over 22 months Christopher Spates MS III, Tana Parker MD

C-1

17004

C-2

17014

DEPARTMENT OF EMERGENCY MEDICINE

EM: C-1 Applicant: Jing Liu MD

Acute myocardial infarction with simultaneous gastric perforation Alon Kaplan MD 1 , Dan Schwarzfuchs MD 1 , Vladimir Zeldetz MD 1 , Jing Liu MD 2 1 Soroka University Medical Center 2 Kern Medical

INTRODUCTION: Acute myocardial infarction and perforated peptic ulcer disease with associated peritonitis are two disease processes that both require emergent intervention and rarely occur simultaneously. PURPOSE: A 66 y/o female with untreated type 2 diabetes mellitus and hypertension was found to have electrocardiographic (EKG) changes consistent with acute ST-segment elevation myocardial infarction (STEMI) as well as a physical exam consistent with an acute abdomen. CT imaging showed free air in the abdomen suggesting hollow viscus perforation. After a multidisciplinary discussion between emergency medicine, internal medicine, and surgery, the decision was made to proceed with percutaneous coronary intervention (PCI) prior to laparoscopic surgery. The patient was found to have a 99% occlusion of the right coronary artery and a bare metal stent was successfully placed. The patient was transferred to the operating room for laparoscopic surgery which revealed a 2mm perforation of the prepyloric gastric antrum. The perforation was repaired however the patient became hemodynamically unstable at this time requiring high dose vasopressors. A repeat PCI was performed demonstrating early subacute stent thrombosis. The thrombus was partially evacuated and an additional stent was placed, however the patient expired in the cardiac critical care unit shortly afterwards. DISCUSSION: While STEMI can manifest clinically with epigastric complaints, perforated viscus may also have accompanying ischemic changes on EKG. There is limited research regarding the two disease processes occurring simultaneously, and cardiac pathology may be easily missed without high clinical suspicion. There is mixed evidence regarding whether to proceed with surgery or PCI first given this scenario, however there is extensive literature suggesting that early PCI in the setting of STEMI has improved outcomes. Studies suggest that cardiac catheterization within 90 minutes is associated with lower rates of in hospital mortality as well as decreased mortality at 30 days as well as 1 year. Perforated peptic ulcer disease has been demonstrated to have a mortality rate of approximately 10%, and a delay in treatment over 24 hours from time of symptom onset has been established as an independent predictor of 30 day mortality. CONCLUSION: In patients found to have concurrent medical emergencies, recognition of all relevant disease processes is crucial. Determining the most effective sequence of treatment is not always readily apparent. Multidisciplinary discussions may aid in deciding how to proceed however a clearly established algorithm may facilitate the treatment of these patients.

Figure: PCI shows an occlusion in the RCA

EM: C-2

Applicant: Amanda Montgomery MD

Avulsion of the lesser trochanter following a shot put sport session Mohamed Habib Grissa MD 1, 2 ; Nasri Bzeouich MD 1, 2 ; Makrim Zrig MD 2 ; Hamdi Boubaker MD 1, 2 ; Mohamed Amine Msolli MD 1, 2 ; Abderrazak Abid MD 2 ; Semir Nouira MD 1, 2 & Amanda Montgomery MD 3

1 University of Monastir, Dept. of Emergency Medicine 2 Fattouma Bourguiba University Hospital 3 Kern Medical, Dept. of Emergency Medicine

INTRODUCTION

Avulsion of the lesser trochanter is an uncommon injury. The mechanism by which it occurred in this particular case was unusual, prompting a close look. PURPOSE A 14 year old male sustained an avulsion fracture to the lesser trochanter of his left leg during a shot put session. The injury occurred without blunt force to the affected area but rather through forceful abduction and external rotation of the left hip. DISCUSSION This case warrants discussion for several reasons. First, the injury that occurred is rare. This case may prompt providers who have not seen this particular injury to have appropriate clinical suspicion in similarly presenting cases. Second, the mechanism of injury during an upper body exertion may not prompt an emergency physician to obtain imaging of the painful area. In the absence of blunt force trauma, suspicion of this type of injury may be low and the avulsion could easily be missed. Third, it is important to educate providers on proper management of this type of case. Treatment for this injury is primarily conservative and nonsurgical. Bed rest and non-weight bearing status are an important part of the recovery process. CONCLUSION The emergency physician must keep this type of injury on the differential diagnosis of a patient with similar presenting symptoms. In cases with high clinical suspicion, it is reasonable to order imaging studies to avoid a missed injury and potential permanent disability.

EM: M-1 (Faculty Presentation)

Faculty Presenter: Khoa Tu MD Principal Investigator: James Rosbrugh MD

Text messaging versus email for emergency medicine residents’ knowledge retention: A pilot comparison in the United States Wirachin Hoonpongsimanont 1 , Miriam Kulkarni 2 , Pedro Tomas-Domingo 1 , Craig Anderson 1 , Denise McCormack 2 , Khoa Tu 3 , Bharath Chakravarthy 1 , Shahram Lotfipour 1, James Rosbrugh 4 1 Department of Emergency Medicine, University of California, Irvine School of Medicine, Orange, CA 2 Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 3 Department of Emergency Medicine, Kern Medical, Bakersfield, CA INTRODUCTION : A majority of residents are part of a techno-literate generation known as Millennials. Traditional classroom lectures and readings are not preferable learning methods for this generation. Millennials are accustomed to using technology and mobile phones in their everyday lives, including their education. A Pew Research Center study found that 95% of (18 -29 years-old) American cell phone owners reported using text messaging services daily. Another study found that 77% of the college students reported sending and receiving emails daily. Integrating text messaging and email into curriculums could improve students’ learning efficiency. One study reported that sending concise exercises to students via mobile devices demonstrated favorable results in class attendance, students’ performance, and motivation. Using text messaging to deliver medical knowledge was a positive influence in nursing academic studies. Another study noted that asynchronous communication (email) could lead to a richer learning experience. PURPOSE: We evaluated the effectiveness of text messaging versus email, as a delivery method to enhance knowledge retention of emergency medicine (EM) content in EM residents. We hypothesized that EM residents who received daily text messages would have better knowledge retention than those who received email. METHOD: We performed a multi-centered, prospective, randomized study consisting of postgraduate year (PGY) 1 to PGY 3 & 4 residents in three United States EM residency programs in 2014. Fifty eight residents were randomized into 2 delivery groups: text message or email. One hundred messages were sent in a two-month period to the text group. The email group received a one-time email in the middle of the two-month period, which contained identical material that was sent to the text group. Participants completed a 40 question pre- and post-intervention exam. The pre-intervention exams assessed residents’ baseline knowledge, while post- intervention exams assessed the amount of retained knowledge after exposure to the interventions. RESULTS: We noticed that exam score differences in the text group were less negative than those of the email group, alluding to more knowledge retention in the text group. However, this finding was not statistically significant even though we obtained an adequate sample size. DISCUSSION: Overall, the means of exam score differences were negative in value, meaning that residents had higher pre-intervention exam scores than post-intervention exam scores. We administered a set of pre- intervention exams shortly after an EM ABEM in-training exam, an exam used to assess an individual resident’s progress towards obtaining ABEM certification. Negative exam score differences may be accounted for by residents’ efforts in preparing for the in-training exam. CONCLUSIONS: Use of text messaging or email to deliver EM education material did not enhance resident knowledge. Lastly, the use of asynchronous learning did not impact knowledge retention.

DEPARTMENT OF MEDICINE

IM: M-1

Applicant & Principal Investigator: Ali Ammar MD

Discharge hypertension as a predictor of 90 day readmission in heart failure patients with reduced ejection fraction Ali Ammar MD, Jeffrey Coleman MS IV , Saman Ratnayake, MD

INTRODUCTION Heart failure (HF) is a serious, chronic, and progressive condition that may require hospitalization if decompensated. Each year, in the United States there are approximately 1 million hospitalizations due to decompensated HF, which costs approximately $39 billion annually. PURPOSE The objective of this study was to describe the frequency of hospital readmissions for patients with HF with respect to their blood pressure on discharge. METHODS In this retrospective study, 400 patients were identified with study criteria of age ≥ 65, low left ventricular ejection fraction (LVEF) defined as < 40% and either high or normal blood pressure on discharge . 200 patients with high blood pressure defined as systolic blood pressure > 160 mmHg and/or diastolic blood pressure >100mmHg on discharge were identified (July, 2015 to July, 2016). Data was collected through uniform query of a community hospital database. Data were collected on patient demographics, medical history, laboratory findings, antihypertensive therapies, hospital associated events, readmission within 90 days of hospital discharge, and admission to ICU within 90 days, following the index hospitalization. DISCUSSION The 90-day readmission rate of HF patients discharged with high blood pressure was 36% (72/200). Of those patients 33% (24/72) were readmitted more than once. Conversely, only 14% (28/200) of HF patients discharged with systolic blood pressure less than 160 required readmission. Of those patients 7% (2/28) were readmitted more than once. Patients discharged with systolic blood pressure >160 had a significantly greater overall readmission rate with p value of 0.0278. CONCLUSION Blood pressure control on discharge is important to decrease readmission.

IM: M-2 Applicant & Principal Investigator: Ali Ammar MD

BMI as a predictor of 90 day readmission in heart failure patients with reduced ejection fraction

Ali Ammar MD, Jeffrey Coleman MS IV, Saman Ratnayake MD

INTRODUCTION Heart Failure (HF) is a serious, chronic, and progressive condition that may require hospitalization if decompensated. Each year, in the United States there are approximately 1 million hospitalizations due to decompensated HF, which costs approximately $39 billion annually. PURPOSE The objective of this study was to describe the frequency of hospital readmissions for patients with HF with respect to their BMI. METHOD In this retrospective study, 300 HF patients with low left ventricular ejection fraction (LVEF) and increased BMI (July, 2015 to July, 2016). Eligible patients were ≥65 years old, had an established diagnosis of HF, with LVEF <40%. The patients were divided into 3 groups: 100 patients with BMI < 30 (normal), 100 patients with BMI 30-40 (mild-moderate obesity), and 100 patients with BMI > 40 (severe obesity). Data was collected through uniform data query of a community hospital databases. Data were collected on patient demographics, medical history, laboratory findings, antihypertensive therapies, hospital associated events, readmission within 90 days of hospital discharge, and admission to ICU within 90 days, following the index hospitalization. RESULTS The 90-day readmission rate of all patients was 26% (78/300). Of those patients 10% (8/78) were readmitted more than once. Conversely, only 23% (23/100) of HF patients with BMI of 30-40 required readmission. Of those patients 4% (1/23) were readmitted more than once. Patients with a BMI of 30-40 had a significantly lesser overall readmission rate (P = <0.05). Patients with BMI < 30 had a readmission rate of 30% (30/100). Of those 10% (3/30) were readmitted more than once. Patients with a BMI >40 had a readmission rate of25% (25/100). Of those 8% (2/25) were readmitted more than once. Patients with a BMI >40 had a significantly lower readmission rate (P = < 0.05). DISCUSSION More than one third of patients discharged home after hospitalization for HF were re-hospitalized at least once within 90 days for heart failure exacerbation. The presence of mild to moderate obesity was significantly associated with a decreased readmission rate. The presence of severe obesity was associated with significant decreased readmissions when compared to normal BMI. Further studies are warranted to determine the impact of other variables on readmission rates and clinical outcomes in this population. CONCLUSIONS Obesity may be a protective factor for heart failure.

IM: C-1

Applicant & Principal Investigator: Ali Ammar MD

Coccidioidomycosis disseminated to the mastoid bone Ali Ammar MD, Greti Petersen MD, Caitlyn Duffin MS IV, Arash Heidari MD

INTRODUCTION Coccidioidomycosis is a fungal pathogen that has a history of repeated infections primarily in Southwestern United States and Northern Mexico. Manifestations of coccidioidomycosis infections can range from pneumonia to organ and tissue dissemination. PURPOSE To present a case of coccidioidomycosis disseminated to the mastoid bone. DISCUSSION This is a 27-year old Hispanic male with type I diabetes mellitus and disseminated coccidioidomycosis involving the lungs and left knee. He presented to the emergency roommultiple times over several months complaining of unilateral hearing loss, ear pain and purulent otorrhea leading to resection of the left mastoid process. Mastoid bone biopsy identified epithelioid granulomas enclosing spherules with endospores, thus establishing the diagnosis of disseminated coccidioidomycosis. Post-operatively, the patient had multiple readmissions after presenting with subjective fevers, multiple episodes of emesis, worsening cachexia and grand mal seizures. This is an extremely unusual because there is no such prior case documented in an adult in the literature. CONCLUSION

Consider disseminated coccidioidomycosis in a patient with unexplained hearing loss and pain.

IM: C-2

Applicant: Aarushi Parekh MD Principal Investigator: Greti Petersen MD

Bell’s palsy: presenting with hemiparesis Aarushi Parekh MD, Ahana Sandhu MD, Greti Petersen, MD

INTRODUCTION

This is the first case report presenting this disease.

PURPOSE A 31year old obese Hispanic female without past medical history has not seen a medical doctor for at least 5 years. She developed left eye twitching, blurred vision in the left eye in, and 40 minutes around lunchtime later felt numbness in the left mouth and tongue with some difficulty chewing without any trouble swallowing. At dinner time, the left tongue was tingling and in the morning she noticed that the left upper and lower face were weak. At about 11 a.m. when driving herself to the ED, she felt her left arm and leg become numb and mildly weak. Upon presentation to the ED, stroke code was called. NIHSS was found to be 5, three for left upper and lower facial weakness, 1 for left leg drift, and 1 for decreased sensation in the left side. She was deemed not a tPA candidate because her symptoms were subacute and had been 24 hours since initiation of symptoms. All imaging of brain and neck were unremarkable. Her lipid panel showed total cholesterol 273 mg/dl and LDL 209 mg/dl. Her liver function test consisted of alkaline phosphate 66 U/L, ALT 86 U/dl, and AST 60 U/L. Her random blood glucose was 200 and hemoglobin A1C 6.5%. Her left arm and leg weakness had resolved by 4-5 pm on the day of presentation to the hospital. The next day in the hospital, she continued to have left upper and lower face weakness, dryness of the left eye, and decreased taste in the left side of the mouth. DISCUSSION There has been a report of patients presenting to Emergency Department who had ischemic stroke being misdiagnosed with Bell’s Palsy. There has also been reports of pontine stroke and pontine hemorrhage being misdiagnosed with Bell’s Palsy. In the future, with a patient presenting with signs mimicking Bell’s palsy, it is important to evaluate for additional cranial neuropathies as well as being cognizant of multiple reports of Bell’s palsy being misdiagnosed. CONCLUSION

Facial palsy should not always be attributed to Bell’s palsy as it is a diagnosis of exclusion.

IM: C-3

Applicant: Aarushi Parekh MD Principal Investigator: Ralph Garcia-Pacheco MD

Diffuse alveolar hemorrhage and rituximab Aarushi Parekh MD, Ralph Garcia-Pacheco MD

INTRODUCTION

Diffuse alveolar hemorrhage (DAH) can be life-threatening. Early treatment with immunosuppressant can be necessary and Rituximab, even one dose, can be life-saving. PURPOSE Patient is a 32 year old obese Hispanic male with suspected obstructive sleep apnea/obesity hypoventilation syndrome but no diagnosed past medical history. Initially had dyspnea, cough, and hemoptysis in 2013 with CT chest showing bilateral extensive ground glass, and was treated with antibiotics, Solumedrol, and Plaquaneil with improvement of symptoms and lost to follow up. In 2015 patient had hemoptysis and dramatic hypoxia with CT chest findings suspicious for interstitial process. Rhemuatology panel returned positive for ANA. He did not improve on antibiotics; he was started on high dose steroids however he did not improve and, ultimately, received one dose of rituximab. CT chest positive for ground glass opacities and traction bronchiectasis. Due to significant hypoxia, bronchoscopy was not performed prior to starting steroids and rituximab. Patient was transferred to tertiary care center and bronchoscopy with bronchoalveolar lavage (BAL) was positive for hemosiderin laden macrophages. BAL flow cytometry was positive for moderate CD45. BAL culture was positive for Mycobacterium Mucogenicum. Patient had dramatic clinical improvement with 1 dose of rituximab. He was started on tapering dose of steroids and titrated off oxygen. At tertiary care center, all rheumatology work up was negative. DISCUSSION Most common reason for DAH can be secondary to autoimmune process mediating capillaritis. Isolated pauciimune pulmonary capillaritis (IPPC) is a rare cause of DAH. A prospective study of patients with DAH having BAL should undergo flow cytometry and for evaluation of response with Rituximab in patients positive with CD45. CONCLUSION Patients with IPPC seem to present sub-acutely with DAH and one has to approach DAH with a broad perspective. Steroids play a role in DAH with either APS or with IPCC. Immunosuppression is necessary with either of these diseases and if one cannot eliminate IPPC as a differential, rituximab can be utilized.

IM: C-4

Applicant: Shelly Gupta MD Principal Investigator: Rajinderpal S. Chahal MD

Severe aplastic anemia as a complication of autoimmune hyperthyroidism Rajinderpal S Chahal MD, Shelly Gupta MD, Arash Heidari, MD

INTRODUCTION There is growing evidence that aplastic anemia can develop secondary to insult or injury to the pluripotent stem cell in the setting of a T-cell mediated autoimmune pathology. We present a case in which autoimmune hyperthyroidism associated with severe aplastic anemia achieved clinical remission after treatment of patient’s hyperthyroidism with methimazole. PURPOSE Presenting a case of severe aplastic anemia as a complication of automimmune hypothyroidism. DISCUSSION A 29 year El Salvadoran male presented to the Emergency Department in September 2014 with complaint of palpitations, lightheadedness, night sweats, and 50 lb weight loss over several weeks. Complete blood count showed a white blood cell count of 2.9 x 10^3/μL, an absolute neutrophil count of 0.9 x10^3/μL, hemoglobin of 4.9 gram/deciliter, and platelet count of 13 x 10^3/μL. Patient’s thyroid stimulating hormone was noted to be less than 0.01 μIU/mL and free T4 of 2.2 ng/dL. Thyroid peroxidase antibodies were 187 IU/mL and thyroid stimulating immunoglobulins were noted to be 419. A radioactive thyroid scan was positive for multiple goiters consistent with hyperthyroidism. Bone marrow biopsy was performed and was consistent with less than 5% cellularity, flow cytometry for CD55/CD59 was negative. Patient was started on methimazole 2.5mg by mouth three times daily and was discharged with outpatient follow-up. During evaluations in December 2014 and January 2015 patient experienced improvement in all hematopoietic cell lineages and experienced a weight gain of 36.5 lbs along with complete resolution of his clinical symptoms without any treatment of his aplastic anemia. Patient was subsequently lost to follow-up and discontinued methimazole. Patient experienced a relapse of his clinical symptoms in July 2016 with a decrease in all cell lineages. CONCLUSION T-cell mediated autoimmune pathology has been hypothesized to play a central role in the pathogenesis of both hyperthyroidism and aplastic anemia. The presence of autoantibodies against stem cell antigens has been proposed as a mechanism to explain correlational relationships between aplastic anemia and autoimmune diseases including hyperthyroidism, hypothyroidism, celiac’s disease, and autoimmune hepatitis. It is our contention that treatment of the underlying autoimmune phenomenon may induce remission of aplastic anemia.

IM: C-5

Applicant & Principal Investigator: Shelly Gupta MD

Rare Presentation of Metastatic Prostate Cancer Leading to Cranial Nerve Palsies and Paranasal Sinus Masses Shelly Gupta MD, Arash Heidari MD, Edward Williams MS IV, Taylor Barrett MS III

INTRODUCTION Prostate cancer is the most common malignancy of males in the United States, and the second leading cause of cancer death. Primary metastases sites of prostate cancer are blastic bone lesions, however rarely there can be metastases to the brain and paranasal sinuses. PURPOSE Presenting a case report of prostate cancer to the paranasal sinuses and cranial nerve palsies. DISCUSSION A 51 year old Hispanic male presented to the emergency department in January 2015 due to paraspinal pain. Physical examination was significant for thoracic and lumbar spine point tenderness, and an enlarged, nodular prostate by digital rectal examination. Initial PSA levels were elevated at 73ng/mL and elevated alkaline of 927 unit/liter. He underwent prostate biopsy, consistent with adenocarcinoma of the prostate, Gleason grade 9. Due to extensive metastases, patient was started on androgen deprivation therapy. Patient showed initial clinical improvement as well as serologic improvement with normalization of PSA and alkaline phosphatase levels 6 after initiation of therapy. In July 2016 patient presented to the emergency department with worsening right facial numbness, facial asymmetry, right eye pain, right eye diplopia and decreased visual acuity. Neurological was notable for right cranial nerve III palsy with moderate to severe right ptosis, limited medial, up and downward gaze and enlarged nonreactive right pupil; right cranial nerve V palsy with decreased sensation; right cranial VII palsy; and right cranial nerve XII palsy with rippling fasiculations of the tongue. PSA was elevated at 377 ng/mL. MRI of the brain showed an enhancing right temporal lobe mass near the right sphenoid wing, multiple enhancing masses in the sphenoid, ethmoid and maxillary sinuses and an enlarged pituitary gland with associated enhancing mass. CONCLUSION Prostatic metastasis occurs in 70% of cases with bone being the most common site. However, metastases to the brain and paranasal sinuses are extremely rare. Incidence of brain metastases from prostate cancer is approximately 0.16%. Paranasal cavity metastases are usually associated with renal, breast, thyroid or prostate carcinomas. Brain and paranasal cavity involvement indicate extensive dissemination and palliative therapy is the only possible treatment option.

IM: C-6

Applicant & Principal Investigator: Ali Ammar MD

A Case of rapidly progressive frontotemporal dementia triggered by life stressors Ali Ammar MD, Kasey Carling MS III, Jeffrey Coleman MS IV, Saman Ratnayake MD

INTRODUCTION Frontotemporal dementia (FTD) may present in multiple variants, behavioral type variant being the most common. FTD causes significant changes in social behavior and personality due to its association with degeneration of the frontal and temporal lobes of the brain. Typically it progresses over three to five years, and presents in the sixth decade of life. PURPOSE To describe a case of FTD brought on by life stressors. DISCUSSION Frontotemporal dementia (FTD) may present in multiple variants, behavioral type variant being the most common. FTD causes significant changes in social behavior, and personality, due to its association with degeneration of the frontal and temporal lobes of the brain. Typically it progresses over three to five years, and presents in the sixth decade of life. FTD may present in multiple variants, behavioral type variant being the most common. FTD causes significant changes in social behavior, and personality, due to its association with degeneration of the frontal and temporal lobes of the brain. Typically it progresses over three to five years, and presents in the sixth decade of life. PET brain was performed and showed hypometabolism involving the frontal lobes, anterior cingulated gyrus and anterior portions of the temporal lobes in a pattern typical for FTD. It has been 4 months since initial interaction with the patient. Today his cognitive function has deteriorated tremendously. He remains bedbound, shows little apathy, and when he is active he stands in the middle of a room for prolonged periods of time. FTD seldom presents in the third decade and is generally not this acutely progressive. Furthermore, the patient's sudden onset of life stressors may have triggered the acuity and early onset of his disease. CONCLUSION

Frontotemporal dementia can be caused by life stressors.

IM: C-7

Applicant & Principal Investigator: Ali Ammar MD

A case of syndrome of inappropriate antidiuretic hormone secretion (SIADH)induced by disseminated central nervous system (CNS) coccidioidomycosis Ali Ammar MD, Arash Heidari MD, Taylor Barrett MS III, Saman Ratnayake MD INTRODUCTION Coccidioidomycosis is a fungal pathogen that has a history of repeated infections primarily in Southwestern United States and Northern Mexico. Manifestations of coccidioidomycosis infections can range from pneumonia to organ and tissue dissemination. CNS coccidioidomycosis has been described multiple times in the past, but has never been associated with hyponatremia. PURPOSE To describe a case of SIADH induced by disseminated coccidioidomycosis. DISCUSSION We describe a case of a 19 year old female with coccidioidomycosis meningitis after four months of field work in central California. This patient presented to the emergency department with the complaint of an ongoing headaches and subjective fevers for 8 days. She reported associated nausea and vomiting since the onset of her headache. Vitals were within normal limits on admission. Labs: Lumbar puncture showing an elevated opening pressure of 55 cm of H2O and cytology showed a glucose of 17 with and elevated WBC of 2700 with pleocytosis. Gram stains of CSF were repeatedly negative. Serum coccidioidomycosis serology resulted as IgM weakly reactive suggesting acute disseminated coccidioidomycosis meningitis. Serum osmolality was found to be decreased at 252 and urine osmolality was 485 with urine sodium of 92, all of which were consistent with SIADH. Treatment: Patient was treated with fluid restriction and fluconazole 1000mg daily. Continued daily labs were ordered and patient showed persistent hyponatremia as low as 120. Therapeutic serial lumbar punctures were performed in an effort to reduce intracranial pressure until on day 4 when pressures returned to normal. Physical Exam: Positive nuchal rigidity and positive Brudzinki’s and Kernig’s signs.

After two weeks of this therapy, the patient showed significant clinical improvement and sodium normalized.

There have been no cases of SIADH secondary to CNS coccidioidomycosis described in current literature.

CONCLUSION In patients with CNS coccidioidomycosis who also present with unexplained SIADH, CNS coccidioidomycosis should be considered in the differential diagnoses as a potential cause of SIADH.

IM: C-8

Applicant & Principal Investigator: Benson Lee DO

Extrapulmonary tuberculosis presenting as a painful testicular mass Benson Lee DO, Shahab Hillyer MD, Bethany Ann Citerella MS IV, Arash Heidari MD

INTRODUCTION

Dissemination to the epididymis is a relatively rare and underdiagnosed presentation of extrapulmonary tuberculosis. PURPOSE The primary purpose is to describe an atypical clinical presentation, workup, diagnosis and management of male genital tuberculosis presenting as a painful testicular mass. DISCUSSION Mycobacterium Tuberculosis (MTB) is a relatively rare infection in the United States with substantial decline since 1992, falling to a historic low of 2.9 per 100,000 in 2014. Nevertheless, it is still an important cause of infectious disease deaths worldwide, only behind that of HIV. A majority of cases reported in the United States are immigrants from endemic countries which poses a challenge for infectious disease control. Urogenital tuberculosis is the second most common extrapulmonary manifestation of tuberculosis in endemic countries and the third most common in countries with low incidence. In developed, countries, approximately 2-10% of patients with pulmonary tuberculosis also have dissemination to the urogenital system. Of those with urogenital tuberculosis, isolated genital involvement appears to be rare. This 48 year-old Hispanic male patient originally from Mexico, presented with a left painful testicular mass that did not resolve with multiple course of antibiotics. He also had a negative urinalysis and urine cultures for infection. It is important to note that, he had prior exposure to Isoniazid resistant tuberculosis and underwent treatment with Rifampin for latent tuberculosis, which poses another challenge of possible infection with multi- drug resistant TB. This patient eventually underwent surgical resection of his left epididymis, with tissue pathology, stains and cultures positive for MTB. He was started on direct observation therapy with rifampin, isoniazid, pyrazinamide and ethambutol (RIPE). Genital tuberculosis can be confused for malignancy and bacterial causes. It is important to identify this presentation of tuberculosis owing to the highly contagious nature and potential for morbidity and mortality. CONCLUSION Genital tuberculosis is a rare and underdiagnosed manifestation of extrapulmonary tuberculosis and requires a high index of suspicion in patients with relevant risk factors.

IM: C-9

Applicant & Principal Investigator: Samiollah Gholam MD

Extraosseous Ewing’s Sarcoma presenting as a scrotal mass Samiollah Gholam MD, A Scott Ragland DO

INTRODUCTION: Ewing’s sarcoma is a highly malignant, poorly differentiated bone tumor of childhood and adolescence primarily involving diaphysis of long bones; femur, tibia, fibula, and humerus and may also occur in other bony structures and cartilage tissue. It is a very clinically aggressive tumor with high rates of recurrence and distant metastasis. Ewing’s Sarcoma (ES) is the second most malignant bone tumor after osteosarcoma, with the highest incidence in the second decade of life. ES has two forms: more common the osseous form and relatively rare extraosseous form (EES). EES has been reported in various tissues including chest wall, larynx, kidney, esophagus and spinal epidural. Per our knowledge and review of literature, in the following case, we report the first case of ESS presenting as perineal mass. PURPOSE: Rare Case Presentation – first of its kind, has not been reported in literature before. DISCUSSION: 18-year-old Hispanic Male presented to our facility with complaint of testicular swelling of 6 months’ duration with no associated dysuria, hematuria and no history of trauma. The swelling had been progressive with episodic lower back pain. CT abdomen and pelvis with contrast was remarkable for a large heterogeneous mass at the base of the penis with possible extension into the right scrotal sac; destructive lesion involving medial left iliac bone, L2 and T11 suggesting metastasis. This was followed by scrotal U/S which confirmed no involvement of the testis. MRI lumbar spine and pelvis confirmed the lesions at L2 and left medial iliac bone. CT chest was significant for multiple pulmonary nodules of varying sizes and multiple lytic lesions in the thoracic vertebra. Otherwise he had a normal CBC with diff, BMP, LFT and UA. He underwent biopsy by Urology and Interventional Radiology, and both results were positive for ESS. Lab: Cytokeratin AE1/AE3 = Negative. EMA = Negative. Desmin = Negative. CD99 = Positive with strong membrane expression. WT1 = Negative. CA-125 = Negative.

CD45 = Negative. CD57 = Negative. S-100 = Negative. MyoD1 = Negative. FLI-1 = Positive.

This is the first case of ESS manifesting at scrotal mass based on the literature review. As compared to ES, ESS is aggressive with common site of metastasis being the lumbar vertebra and lungs, which was seen in this patient with 5-year survival ranging from 33 to 48%. It is important to keep ESS in differential diagnosis in a young patient with soft tissue mass regardless of the location, a biopsy is warranted. CONCLUSION: ESS can manifest in different tissues; this case demonstrates the first case of ESS as a perineal mass.

IM: C-10

Applicant & Principal Investigator: Samiollah Gholam MD

A Case of Asymptomatic Charcot Marie Tooth Syndrome with Hypersensitivity to Vincristine Roopam Jariwal MS III, Benson Lee DO, Samiollah Gholam MD, A Scott Ragland DO

INTRODUCTION: Charcot Marie Tooth (CMT) is among one of the most common hereditary sensory and motor neuropathies. It is classified into seven types (CMT1 -7). Inheritance patterns include Autosomal Dominant, Autosomal Recessive, and X-linked Recessive. Most common form is CMT1A with an autosomal dominant pattern involving mutation in myelin protein 22 (MP22) gene. All forms of CMT involve demyelination of the peripheral nerves system. Prevalence is approximately 1 in 2,500 cases with a bimodal age distribution; either symptomatic at childhood or third and fourth decades of live. Based on the literature review, there are a subset of individuals that may have the physical findings of CMT such as pes cavus, hammertoes, calf muscle hypertrophy, painless and symmetric motor neuropathy, sensory loss involving vibration and proprioception and diminished deep tendon reflexes, however remain clinically silent. Here we report a case of CMT that was clinically quiescent and unmasked due to hypersensitivity to Vincristine. PURPOSE: Rare Case Presentation. DISCUSSION: 56-year-old Hispanic female presented with complaints of bilateral upper and lower extremities weakness and numbness s/p 10 days after 2nd cycle of R-CHOP therapy that she was receiving for large B-cell lymphoma. The symptoms started 4 days post 1st cycle of R-CHOP therapy with mild weakness and numbness in the tips of fingers and toes. The peripheral neuropathy worsened 10 days after 2nd cycle of R-CHOP containing low-dose Vincristine with patient now being unable to walk, perform daily living activities and being completely bed ridden. Physical examination showed severe motor weakness and decreased sensation to light touch and pinprick in bilateral upper and lower extremities, up to the knees and elbows, along with pes cavus and hammertoes in both feet. Upon further investigation, several family members in patient’s family including her father and three siblings had been diagnosed with Charcot Marie Tooth disease and patient herself had difficulty walking due to severe pes cavus since she was 50 years old. Nerve conduction and electromyogram studies of bilateral upper and lower extremities indicated severe diffuse sensory motor neuropathy with absent action potentials, severe active denervation in forearm, hands, lower leg muscles, and proximal leg muscles. Asymptomatic Charcot Marie Tooth disease can manifest in the 4 th or 5 th decade of life in the presence of neurotoxic drugs such as Vincristine. Review of previous literature indicates evidence of similar occurrences. The hallmark features of CMT 1-7 include pes cavus/valgus, hammertoes, bilateral foot drops, symmetric and bilateral weakness, loss of proprioception and sensation, loss of deep tendon reflexes, along with scoliosis, and other spine deformities. Patients who present with these symptoms and have a family history of neuropathy should receive thorough physical and foot examination. Nerve conduction, electromyogram, sural nerve biopsies and genetic testing to search for one of the 28 identified genes can be used as diagnostic tests to confirm diagnosis. Nerve biopsies show nerve hypertrophy with onion bulb formation caused by repeated demyelination and remyelination due to Schwann cell dysfunction. CONCLUSION: Severe neurotoxic effects of Vincristine along with subclinical Charcot Marie Tooth were attributed to patient’s presentation. It is pertinent to perform a thorough physical and neurological examination in patients with family history of hereditary neuropathies before administering neurotoxic drugs.

IM: C-11

Applicant & Principal Investigator: Samiollah Gholam MD

A rare case of downhill esophageal varices in the absence of superior vena cava obstruction Samiollah Gholam MD 1 ,Sehem Ghazala MD 2 , Bupesh Pokhra MD 3 , Archita Desai MD 3 1 Department of Medicine, Kern Medical 2 Department of Medicine, Banner University Medical Center – Tucson 3 Division of Gastroenterology, Department of Medicine, Banner University of Arizona – Tucson INTRODUCTION: Esophageal varices are dilated veins of the sub-epithelial connective tissue. They are characterized into two major classes: uphill - increased portal venous pressure leads to “upward” venous flow via dilated esophageal collaterals towards the superior vena cava (SVC). Downhill varices are primarily due to superior vena cava obstruction leading to “downward” venous flow via esophageal collaterals towards the portal vein and inferior vena cava. Downhill varices without superior vena cava (SVC) obstruction are rare. PURPOSE: To present the first published case of an 87 year old female patient with downhill esophageal varices secondary to severe aortic stenosis and pulmonary hypertension, with no intra-thoracic mass or evidence of SVC obstruction. DISCUSSION: Concurrent hypothyroidism, hypertension and cognitive impairment; Physical examination unremarkable (no pedal edema, CVP, nor ascites). Laboratory findings: hemoglobin of 5.6 g/dL, Platelet 386 (1000/uL), ALT 109 IU/L, AST of 60 IU/L, Sodium 140 mMol/L, INR 1.1, BNP >3000 and Hepatitis negative. Social history negative (EtOH, risk factors - liver disease). CXR: pulmonary edema/bilateral pleural effusion. 2-D echocardiogram showed severe valvular aortic stenosis and RVSP 60+ mmHg. MRI of the chest/abdomen/pelvis - discrete mid-esophageal varices without advanced chronic liver disease or portal hypertension, significant for cardiomegaly, bilateral pleural effusion. No prior EDG or colonoscopy. Upper endoscopy (two columns of grade II-III varices were found in the upper third of the esophagus without stigmata of bleeding) and findings (large hiatal hernia/multiple superficial erosions in the hernia sac suggestive of Cameron ulcers; diffuse severe inflammation/linear erosions, shallow ulcerations) found in the entire examined stomach. Biopsy sent for Helicobacter Pylori testing. Colonoscopy revealed diverticulosis in the sigmoid colon, internal hemorrhoids, no evidence of bleed. Anemia was attributed to hiatal hernia and gastric ulcers. She was placed on double dose PPI for 3 months, discharged in stable condition. A multidisciplinary meeting recommended outpatient follow-up & TAVR (cardiology). This case demonstrated the presence of “downhill” varices in the setting of pulmonary hypertension caused by aortic stenosis without of SVC obstruction and liver cirrhosis. The mild elevation (AST, ALT) are attributed to liver congestion secondary to pulmonary hypertension. CONCLUSION: Downhill varices are fairly common in the presence of SVC obstruction, reported in as many as 30% of patients. However, bleeding from downhill esophageal varices is rare and accounts for approximately 0.4 -10% of variceal bleeds. The treatment for downhill varices includes treating the underlying cause, e.g. aortic stenosis. Although there have been few case reports of pulmonary hypertension and downhill varices, to our knowledge, this is the first case of downhill esophageal varices in aortic stenosis induced pulmonary hypertension in the absence of liver disease. CT or MRI of the chest may be indicated in anemic patients with pulmonary hypertension for concern of downhill esophageal varices.