Aslam, Saher

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Graduate Medical Education Research Journal Volume 6 Issue 1 Article 61 June 2024 Looking at ANCA Vasculitis Saher Aslam University of Nebraska Medical Center Tell us how you used this information in this short survey. Follow this and additional works at: https://digitalcommons.unmc.edu/gmerj  Part of the Higher Education Commons, and the Medicine and Health Sciences Commons Recommended Citation Aslam, S. Looking at ANCA Vasculitis. Graduate Medical Education Research Journal. 2024 Jun 28; 6(1). https://digitalcommons.unmc.edu/gmerj/vol6/iss1/61 This Conference Proceeding is brought to you for free and open access by DigitalCommons@UNMC. It has been accepted for inclusion in Graduate Medical Education Research Journal by an authorized editor of DigitalCommons@UNMC. For more information, please contact digitalcommons@unmc.edu. Looking at ANCA Vasculitis Abstract NA Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. This conference proceeding is available in Graduate Medical Education Research Journal: https://digitalcommons.unmc.edu/gmerj/vol6/iss1/61 June 2024  |  Vol. 6  |  Issue 1 Poster Presentations 52*Names in bold type indicate presenting author.#62. The GIPP Never Lies: A Case of Refractory Ulcerative ColitisKyle J. Scholten1, Kevin Brittan1, Luis Zuniga1, Kathryn Hutchins2 1Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA  2Department of Internal Medicine, Division of Gastroenterology & Hepatology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USAMentor: Kathryn HutchinsProgram: Internal MedicineType: Case ReportBackground: Listeria Monocytogenes is a rare infection with approximately 800 confirmed cases per year. The pathogen can present as a mild infection but can be more severe in immunocompromised patients. We present a case of invasive listeriosis in an ulcerative colitis patient. Case: A 58-year-old male with a past medical history significant for refractory ulcerative colitis (UC) presented to the emergency department after 3-days of worsening hematochezia and abdominal pain. Patient had transitioned to ustekinumab from infliximab and started a 40 mg prednisone taper two weeks prior due to refractory UC symptoms. On admission, the heart rate was 125, blood pressure was 82/55, and temperature was 102.1. Pertinent labs included white blood cell count 20.8, procalcitonin 0.37, lactic acid 1.7, and CRP <0.5. Patient was given fluids and broad-spectrum antibiotics along with methylprednisolone. CT significant for mild to moderate mural thickening in distal colon and rectum. Gastrointestinal pathogen panel (GIPP) was negative. Flexible sigmoidoscopy revealed diffuse disease consistent with active ulcerative colitis the following day. Two days after admission, 2/2 blood cultures were positive for Listeria Monocytogenes. Infectious disease was consulted, and the patient was treated with ampicillin and gentamicin. Following treatment initiation, hematochezia decreased, and abdominal pain subsided. Patient was discharged on amoxi-cillin with a continued prednisone taper and mesalamine suppositories without recurrence of symptoms. Conclusion: Patients on immunosuppressive therapy are at higher risk of developing listeri-osis. Clinicians should be aware that listeria is not a tested pathogen on GIPP and can present as invasive diarrhea.#63. Exploring the Efficacy of Pulmonary Artery Pressure Monitoring in Rural LVAD Patients: A Retrospective Cohort Study on Clinical Outcomes Landon Withrow1, Blake Kooima1, Scott Lundgren2, Elizabeth Lyden3 1Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA  2Department of Internal Medicine, Division of Cardiovascular Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA  3Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USAMentor: Scott Lundgren Program: Internal Medicine Type: Original Research Background: Rural healthcare challenges impede equitable care of advanced heart failure patients with left ventricular assist devices (LVAD) due to poor access to special-ized resources. Remote pulmonary artery pressure (PAP) monitoring offers a potential solution to improve clinical outcomes in these patients. Methods: A retrospective cohort study was conducted at an academic tertiary care center on adults 19 years or older implanted with LVADs between January 2015 and May 2022. Participants included resided in counties with populations under 50,000 as per the 2020 census. The study used the CardioMEMS PAP monitor by Abbott Laboratories in Abbott Park, Illinois. The primary outcome was the rate of right heart failure hospitalizations, with secondary outcomes including time-to-event of first right heart failure hospitalization post-LVAD implantation and overall survival. Results: A total of 156 patients underwent LVAD implantation during the study period. Twenty-four patients had concurrent PAP monitors in place. The PAP monitor group showed a higher mean hospitalization rate for right heart failure (1.1383 per patient year) compared to the non-PAP monitor group (0.5024 per patient year) with a significant p-value of 0.0481. The PAP monitor group had a significantly shorter time-to-event of first right heart failure hospitalization (p=0.0162) (Figure 1). No statistically signifi-cant difference in survival was noted between the groups (p=0.2849). Table 1. Mean, standard deviation, and IQR of common gastroenterological procedure costs comparing all, academic, and private hospitals. US  CompleteCT  Abdomen with ContrastMRI Abdomen with ContrastLiver Elastography EGD (outpatient)Colonoscopy Screening Liver Biopsy IRLiver Biopsy PercutaneousAll HospitalsMean 742.13 2579.98 3494.29 172.76 3141.28 4617.89 952.68 6717.58Standard Deviation 602.41 1772.17 1793.03 48.09 1446.46 4518.85 524.26 4298.29IQR 513.63 1296.03 2532.48 25.74 2564.17 2280.58 454.03 5675Academic Hospitals Mean 971.49 3001.66 3608.17 162.35 3665.42 4416.29 952.68 9907.5Standard Deviation 626.50 2555.68 2093.95 53.09 1584.54 2163 524.26 2741.45Private HospitalsMean 673.69 2211.02 3394.66 204 3050.18 4994.16 N/A 5441.61Standard Deviation 574.66 591.04 1627.06 N/A 1390.85 5594.19 N/A 4325.64Graduate Medical Education Research Journal53 Poster Presentations*Names in bold type indicate presenting author.Conclusion: PAP monitor implantation in this rural patient cohort does not demonstrate clin-ical benefit in heart failure outcomes. Certain statistical observations may be influenced by selection bias in this retrospective study, potentially favoring the preferential choice of more complex patients for PAP monitor implantation. #64.Looking at ANCA VasculitisSaher Aslam1, Eric Magliulo1, Kirk W. Foster2, Felipe S. Naranjo1 1Department of Internal Medicine, Division of Nephrology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA 2Department of Pathology, Microbiology & Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USAMentor: Felipe S. NaranjoProgram: Internal Medicine – NephrologyType: Case ReportBackground: Anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of autoimmune diseases that can cause inflammation and damage to small blood vessels throughout the body. Inflammatory eye disease is described in 50% to 60% of patients with AAV, and for 8% to 16% of patients, it is an initial manifestation. Case: A 74-year-old man with a history of chronic sinusitis and chronic kidney disease (G3a) presented to clinic with worsening kidney function and proteinuria without hematuria. He was seen by Ophthalmology a few months prior for scleritis and was treated with a course of NSAIDs, with symptomatic improvement. Kidney biopsy showed a lesion of focal segmental sclerosis with obliteration of the capillary lumen, mild interstitial fibrosis and tubular atrophy, immunofluorescence was negative and electron microscopy with rare small dense deposits. The patient was started on SGLT-2 inhibitors. Renal function continued to deteriorate. The patient’s condi-tion was complicated by acute bronchitis, diffuse anterior scleritis, acute kidney injury, labs revealed positive ANCA antibodies with elevated PR3 antibodies. Repeat kidney biopsy revealed necrotizing crescentic glomerulonephritis. He was treated with IV steroids, rituximab and ultimately required dialysis. Conclusion: Renal involvement is a signif-icant feature of AAV and can lead to acute kidney injury or chronic renal failure if left untreated. Clinicians should consider AAV in the differential diagnosis of patients presenting with scleritis, especially in those with renal dysfunction even with partial or complete resolution in ocular symptoms. Early diagnosis and treatment are essential in preventing irreversible organ damage and improving patient outcomes. #65. Acute Gastroparesis Following Atrial Fibrillation AblationMitch Sand1, Rees Adomako2, Jason Payne21Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA 2Department of Internal Medicine, Division of Cardiovascular Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USAMentor: Jason PayneProgram: Internal MedicineType: Case ReportBackground: Gastroparesis is a seldomly reported complication of atrial fibrillation ablation but reports of less severe gastrointes-tinal symptoms are more common reported as high as 50% of the time. The mechanism of injury is believed to be collateral periesopha-geal vagal nerve injury. Case: A 67-year-old male presented with progressively worsening chest pain, abdom-inal distention and nausea six days after pulmonary vein isolation with radiofrequency ablation for atrial fibrillation (AF). Esophageal temperature monitoring was utilized throughout ablation and peak temperature was 36.2C. Prior to ablation he had no Figure 1. A visual depiction illustrating the time-to-event analysis for the occurrence of the initial hospi-talization due tto right heart failure after LVAD implantation.June 2024  |  Vol. 6  |  Issue 1 Poster Presentations 54*Names in bold type indicate presenting author.gastrointestinal symptoms. CT abdomen and pelvis showed a massively dilated stomach (Figure 1A) compared to previous CT (Figure 1B) within a year prior to AF ablation with normal appearing stomach. A nasogas-tric tube was placed for decompression and gastroenterology was consulted. He under-went esophagogastroduodenoscopy (EGD), showing patent pylorus and large amount of gastric contents, which was suctioned with no evidence of mechanical obstruction. He was managed with metoclopramide, liquid diet and fully recovered clinically.Conclusion: Given the proximity of the vagal nerve to the pulmonary vein, we believe that there was collateral insult to the vagal nerve leading to his acute gastric atony. Our case highlights a rare complication of acute gastric atony following pulmonary vein isolation and should be on the differential for patients presenting with acute gastrointestinal symp-toms following AF ablation. #66. When Inflammatory Arthritis Gets Rash, Consider PsAPASH Morgan Newlun1, Nicholas Yeutter1, RemyGrace Sass1, Amy Dreessen11Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA Mentor: Amy DreessenProgram: Internal MedicineType: Case ReportBackground: PsAPASH – psoriatic arthritis, acne, pyoderma gangrenosum, and hidrad-enitis suppurativa – is an autoinflammatory syndrome caused by innate immune system dysfunction, resulting in significant inflamma-tory arthritis, skin lesions, and joint pain. This rare syndrome and similar “P-syndromes” are a diagnostic puzzle and require a multidisci-plinary approach for prompt recognition and treatment. Case: A 41-year-old man presented with 6 years of chronic bilateral knee pain and tender skin lesions. He endorsed joint pain and fatigue but denied fever, chills, and night sweats. Examination revealed tachy-cardia, severe cribriform scarring over his face, axillae, and groin, ulcerated and open groin lesions, diffuse muscle wasting with proximal muscle weakness, large bilateral knee effusions without warmth or tender-ness, and multiple metatarsophalangeal joints with subluxation. Initial labs showed an elevated erythrocyte sedimentation rate, elevated c-reactive protein, leukocytosis, and an elevated protein gap. Bilateral knee x-rays and foot x-rays demonstrated multi-focal osseous erosions with large knee joint effusions and polyarticular inflammatory arthritis in multiple metatarsophalangeal and interphalangeal joints. The patient declined joint aspiration. Rheumatology was consulted, and additional infectious and rheu-matologic workup was within normal limits. Dermatology was consulted and felt his skin manifestations were consistent with infected hidradenitis suppurativa lesions and pyoderma gangrenosum on his abdomen. Dermatology and rheumatology deemed the constellation of symptoms appeared consistent with PsAPASH syndrome.Conclusion: He was started on steroids for his inflammatory arthritis, doxycycline for his infected hidradenitis suppurativa, and a tumor necrosis factor-alpha inhibitor for disease-modifying treatment. He was discharged with close follow-up, noting improvement in his pain and quality of life.#70. Follicular Mucinosis and Cutaneous T-Cell Lymphoma Association: A Clinicopathologic and Molecular Analysis of 19 Cases Ahmad Alshomrani1, Ketav Desai1, Allison Vokoun1, Ab Rauf Shah1, Ann Crowley1, Dinesh Pradhan1, Joseph D. Khoury1, Safina Hafeez11Department of Pathology, Microbiology & Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA Mentor: Safina HafeezProgram: Pathology Type: Original ResearchBackground: Follicular mucinosis is a rare dermatologic disorder characterized by the accumulation of mucin within hair follicles, resulting in distinct skin lesions. It can be associated with cutaneous T-cell lymphoma (CTCL), further complicating its management. Methods: We identified 19 cases of follicular mucinosis from 2010 to 2023. We assessed hematoxylin and eosin (H&E) stained slides for mucin presence and lymphocytic infiltrate. Immunostains and T-cell receptor (TCR) gene rearrangement analysis was performed to investigate clonality. Results: Patients aged 12 to 87 years (median age: 38), with 11 males and 8 females, were included. Biopsies were obtained from various anatomical sites (Table 1). All cases exhibited mucin accumulation within hair follicles, confirming follicular mucinosis by H&E staining. Immunostains were evaluated to rule out lymphoma, with additional staining Figure 1. CT abdomen and pelvis coronal view showing large stomach (yellow star) with undigested food content (1A) compared to similar image a year prior to AF ablation with normal appearing stom-ach (yellow arrow) (1B).Graduate Medical Education Research Journal55 Poster Presentations*Names in bold type indicate presenting author.(colloidal iron and Alcain blue) supporting mucin deposition. Two cases were associated with mycosis fungoides, and four cases were associated with atypical lymphoid prolif-eration. In the majority of cases (16/19), epidermotropism was not present. However, prominent epidermotropism occurred in 1/2 cases of mycosis fungoides and 1/4 cases of atypical lymphoid proliferation. Additionally, minimal epidermotropism was noted in one case of atypical lymphoid proliferation. TCR gene rearrangement analysis in 17 cases showed clonality in 9 cases. Conclusion: In cases of atypical lymphoid proliferation, TCR gene rearrangement was positive, but there was insufficient evidence to diagnose lymphoma. Close follow-up was recommended. Some cases may exhibit clonal TCR gene rearrangements without T-cell lymphoma evidence, referred to as pseudo-clonality or benign clonality. Distinguishing between true clonality and pseudo-clonality can be challenging.#71. Challenges and Improvements of Vitreous Fluid Processing Protocol in the Diagnosis of Intraocular Lymphomas: A 13-Year Institutional ReviewJordan Burr1, Thomas Auen1, Ana Yuil-Valdes11Department of Pathology, Microbiology & Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USAMentor: Ana Yuil-ValdesProgram: Pathology Type: Original ResearchBackground: Upon notification that a vitreous specimen will be sent to our Cytology department, the specimen is deemed a high priority specimen and ran as ‘stat’. Eight cyto-spins are then made; one Diff-Quik stained, one Papanicolaou stained, and six unstained for potential immunocytochemical stains. The cytopathologist will triage the material and decide whether to order immunocytochemical stains, flow cytometry, and molecular studies. We also conducted a 13-year retrospective review to demonstrate the efficacy of our vitreous fluid protocol for the workup and diagnosis of intraocular lymphomas.Methods: Upon notification that a vitreous specimen will be sent to our Cytology depart-ment, the specimen is deemed a high priority specimen and ran as ‘stat’. Eight cytospins are then made; one Diff-Quik stained, one Papanicolaou stained, and six unstained for potential immunocytochemical stains. The cytopathologist will triage the material and decide whether to order immunocytochemical stains, flow cytometry, and molecular studies. We also conducted a 13-year retrospective review to demonstrate the efficacy of our vitreous fluid protocol for the workup and diagnosis of intraocular lymphomas.Results: Thirteen cases of intraocular lymphoma were identified in nine patients. We found this workflow allowed for optimal cell preservation, aiding in the diagnosis of intraocular lymphomas.Conclusion: Cytologic analysis of vitreous specimens is a valuable diagnostic tool in cases of intraocular lymphoma. Developing a multidisciplinary approach for processing vitreous fluid is vital to producing an adequate diagnostic sample. This protocol allowed for the accurate diagnosis of intraocular lymphoma. Table 1. Summary of the clinical and molecular features of follicular mucinosis and cutaneous T-cell lymphoma association.Cases Age Gender Diagnosis Anatomic Site Epidermotropism TCR Gene Rearrangement1 17 M follicular mucinosis Forehead, thigh Not present Positive2 35 F follicular mucinosis with mycosis fungoides Back Not present Positive3 66 M follicular mucinosis Back Not present Positive4 47 M follicular mucinosis Temple Not present Negative5 38 M follicular mucinosis Back Not present The quantity of T-cell-derived DNA was insufficient for a T-cell gene rearrangement study6 38 M follicular mucinosis Back Not present indeterminate for a clonal T-cell population7 13 F follicular mucinosis Back Not present Negative8 68 M follicular mucinosis Elbow Not present Negative9 61 M follicular mucinosis Cheek Not present Suspicious but not diagnostic (small clonal population)10 12 F follicular mucinosis Eyebrow Not present Not performed11 13 M follicular mucinosis Cheek Not present Not performed12 54 M atypical lymphoid proliferation with follicular mucinosisScalp Present Positive13 36 F follicular mucinosis and atypical T-cell proliferation Cheek Not present Positive14 83 M follicular mucinosis with mycosis fungoides Back Present Positive15 87 F follicular mucinosis Cheek Not present Positive16 15 F follicular mucinosis Chin Not present Suspicious but not diagnostic (two sub-threshold peak)17 49 F follicular mucinosis Labia Majora Not present negative18 21 M follicular mucinosis and atypical T-cell proliferation Neck Minimal epidermotropismPositive19 56 F follicular mucinosis and atypical T-cell proliferation Leg Not present Positive

Looking at ANCA Vasculitis

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