Ankle Swelling Research Articles

1423. A Rare Case of Mycobacterium chelonae Septic Joint

Abstract Background Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms that can cause chronic soft tissue infections and which may affect underlying joints and bone by direct extension. NTM septic joint infections are rare and literature on their management is scarce. Methods Here we describe a case of septic ankle due to M. chelonae, a rapid grower NTM, and review treatment of these infections. Results An 86-year-old man presented to our hospital with complaints of a painful left ankle. Three months prior he noticed a pimple on his left foot after tripping over a lawnmower. The lesion evolved into erythema and painful swelling of the left ankle. Magnetic resonance imaging (MRI) of the left lower extremity revealed a fracture of the distal tibial metaphysis. Turbid joint fluid was aspirated showing 211,450 white blood cells with 97% neutrophils. Patient underwent partial removal of the left tibia with insertion of a drug implant device. Culture results showed acid fast bacilli at day three and the pathology report confirmed atypical mycobacterial infection (Fig 1, 2). Empiric meropenem, linezolid, and azithromycin were initiated until the identification of M. chelonae was obtained. Based on susceptibilities meropenem was discontinued and ciprofloxacin was added. A repeat MRI showed osteomyelitis and small abscesses about the left ankle leading to repeat debridement. Cultures from debridement were negative. Tobramycin IV three times a week was added and ciprofloxacin was discontinued. Patient soon developed acute renal failure, NSTEMI, and lactic acidosis. After a goals of care discussion with patient’s family, antibiotics were discontinued. He passed away soon thereafter. The backbone of NTM treatment usually consists of a macrolide plus 2-3 other agents but susceptibilities can be misleading. Data correlating outcomes of in vitro susceptibility and clinical response is mixed. Consequently, management of NTM infections is often derived from case reports and from the tuberculosis literature. As seen in this patient, effective treatment can be elusive. Neutrophils surround vacuoles filled with acid-fast staining organisms on Fite staining H&E Stain shows pink stained organisms in vacuoles Conclusion NTM infections are often resistant to antimycobacterial therapy and require multi-drug regimens with surgical intervention. Due to this complexity, a multidisciplinary approach is vital to improve outcomes. Disclosures All Authors: No reported disclosures.

366 RIGHT HEART FAILURE IN CARCINOID HEART DISEASE: A MULTIDISCIPLINARY APPROACH

Abstract Introduction Carcinoid heart disease occurs in more than 50% of patients with neuroendocrine gastrointestinal tumors, and it is the initial presentation of carcinoid syndrome in up to 20% of patients. The disease is characterized by pathognomonic plaque-like deposits of fibrous tissue in the endocardium of valvular cusps, cardiac chambers, and occasionally, the intima of the pulmonary arteries or aorta. The tricuspid and the pulmonary valve are most often affected by carcinoid disease, with several combinations of valve dysfunction (usually pulmonic stenosis + tricuspid regurgitation). Valvular dysfunction can lead to peripheral edema, ascites and right-sided heart failure, extreme cases may present with low cardiac output syndrome. Valve surgery may relieve symptoms and it should be considered in patients with controlled neoplasia. Case report a 47-years-old man with a history of operated neuroendocrine gastrointestinal tumor (ileal resection+right hemicolectomy+mesenteric lymphadenectomy) was admitted to our department for right heart failure. His clinical examination was remarkable for ankle swelling, flushing, liver congestion, ascites; moreover the patient reported progressive compromise of functional capacity and weight loss due to anorexia. Laboratory findings were in the normal range except for BNP 184 pg/ml (UNL <100 pg/dl). ECG: sinus rhythm 80 bpm, diffuse repolarization abnomarlities. Transthoracic echocardiography showed: severe right chambers remodeling with RV+RA dilatation associated with systo-diastolic septal bulge (pressure + volume overload), torrential tricuspid regurgitation (secondary to fibrotic retraction of valve leaflets and severe coaptation deficiency with apical tethering), moderate-to-severe pulmonic regurgitation associated with valve stenosis; on the left side: mitral and aortic valves were normal, there was mild reduction of left ventricle ejection fraction secondary to ventricular interdipendence. The patient was discussed in Heart Team: right sided valves were both considered responsible for patient's symptoms, so he was scheduled for surgical intervention after achieving adeguate haemodinamic stability. Pre-surgery right catetherization showed normal pulmonary pressures. Coronary arteries were normal. Before, during and after surgery he was treated with octreotide to reduce the risk of Carcinoid Crisis in the perioperative period. The patient underwent surgical replacement of tricuspid and pulmonary valves with biological prosthesis Mosaic n°33 and Avalus n°23 respectively. Histological examination of the valves showed extensive deposits of fibrous tissue in the valvular endocardium. Post-surgical hospital stay was uneventful, the patient was discharged 14 days after surgery on normal sinus rhythm and in good clinical conditions. In order to prevent thromboembolic events anticoagulant therapy with Warfarin was introduced. Conclusion this is the report of a rare cardiac condition responsible for right heart failure symptoms. Heart Team discussion and multidisciplinary approach involving surgeons and oncologist are mandatory in order to establish the best treatment strategy and timing for interventions. However, since this is a rare condition, more evidence is needed to better understand long term clinical outcomes and treatment options (including future percutaneous perspectives).

Imaging of accessory soleus muscle: A case report with review of the literature

The accessory soleus muscle is an uncommon anatomical variant. It usually manifests as ankle pain and swelling or as an asymptomatic soft-tissue mass along the posterior and medial aspect of the ankle. In a few cases, it is sometimes misdiagnosed as a mesenchymal lesion. The idea of this case report was to highlight the existence of accessory soleus muscle mistaken as a mesenchymal tumor on fine needle aspiration cytology (FNAC). A 32-year-old male patient presented to the orthopedics department with a soft swelling in the distal one-third of the left leg posterior to the medial malleolus. The patient noticed this swelling about 5 years back. The swelling was non-tender and non-pulsatile. Before the imaging, FNAC from the swelling was done which raised suspicion of a mesenchymal lesion. He was referred to the radiodiagnosis department for imaging evaluation of the swelling. A radiological diagnosis of accessory soleus muscle was made; ruling out the possibility of a mesenchymal tumor. This accessory muscle is a less common congenital anatomic variant rather than a soft-tissue mass lesion. The characteristic imaging appearance and location of this muscle give a definite diagnosis. Further, it highlights this rare variation pertaining to its calcaneal insertion and relation with the flexor retinaculum and tarsal tunnel, which should be kept in mind by radiologists.

Saussurea involucrata oral liquid regulates gut microbiota and serum metabolism during alleviation of collagen-induced arthritis in rats.

Saussurea involucrata oral liquid (SIOL) can clinically relieve symptoms, such as joint pain and swelling, and morning stiffness, in patients with rheumatoid arthritis (RA). However, the mechanism of action remains unclear. This study used a combination of gut microbiota and serum metabolomics analysis to investigate the effects and potential mechanisms of SIOL intervention on rats with RA induced by type II bovine collagen and Freund's complete adjuvant. Results showed that SIOL treatment consequently improved the degree of ankle joint swelling, joint histopathological changes, joint pathological score, and expression of serum-related inflammatory cytokines (interleukin (IL)-1β, IL-4, IL-6, IL-10, and tumor necrosis factor-α) in RA model rats. 16 S rRNA sequencing results showed that SIOL increased the relative richness of the Lactobacillus and Bacteroides genus and decreased the relative richness of Romboutsia, Alloprevotella, Blautia, and Helicobacter genus. Serum nontargeted metabolomic results indicated that SIOL could regulate metabolites related to metabolic pathways, such as glycine, serine, threonine, galactose, cysteine, and methionine metabolism. Spearman correlation analysis showed that the regulatory effects of SIOL on the tricarboxylic acid (TCA) cycle, phenylalanine metabolism, phenylalanine, tyrosine, and tryptophan biosynthesis, and glyoxylate and dicarboxylate metabolism pathways were correlated with changes in the richness of the Lactobacillus, Romboutsia, Bacteroides, and Alloprevotella genus in the gut microbiome. In conclusion, this study revealed the ameliorative effects of SIOL on RA and suggested that the therapeutic effects of SIOL on RA may be related to the regulation of the community richness of the Lactobacillus, Romboutsia, Bacteroides, and Alloprevotella genus, thereby improving the TCA cycle; phenylalanine metabolism; phenylalanine, tyrosine, and tryptophan biosynthesis, and glyoxylate and dicarboxylate metabolism-related pathways.

Abdominal vagus nerve stimulation alleviates collagen-induced arthritis in rats.

Rheumatoid arthritis (RA) is a chronic, autoimmune inflammatory disease. Despite therapeutic advances, a significant proportion of RA patients are resistant to pharmacological treatment. Stimulation of the cervical vagus nerve is a promising alternative bioelectric neuromodulation therapeutic approach. However, recent clinical trials show cervical vagus nerve stimulation (VNS) was not effective in a significant proportion of drug resistant RA patients. Here we aim to assess if abdominal vagus nerve stimulation reduces disease severity in a collagen-induced arthritis (CIA) rat model. The abdominal vagus nerve of female Dark Agouti rats was implanted and CIA induced using collagen type II injection. VNS (1.6 mA, 200 μs pulse width, 50 μs interphase gap, 27 Hz frequency) was applied to awake freely moving rats for 3 h/day (days 11-17). At 17 days following the collagen injection, unstimulated CIA rats (n = 8) had significantly worse disease activity index, tumor necrosis factor-alpha (TNF-α) and receptor activator of NFκB ligand (RANKL) levels, synovitis and cartilage damage than normal rats (n = 8, Kruskal-Wallis: P < 0.05). However, stimulated CIA rats (n = 5-6) had significantly decreased inflammatory scores and ankle swelling (Kruskal-Wallis: P < 0.05) compared to unstimulated CIA rats (n = 8). Levels of tumor necrosis factor-alpha (TNF-α) remained at undetectable levels in stimulated CIA rats while levels of receptor activator of NFκB ligand (RANKL) were significantly less in stimulated CIA rats compared to unstimulated CIA rats (P < 0.05). Histopathological score of inflammation and cartilage loss in stimulated CIA rats were no different from that of normal (P > 0.05). In conclusion, abdominal VNS alleviates CIA and could be a promising therapy for patients with RA.

Thromboprophylaxis with unilateral pneumatic device led to less edema and blood loss compared to enoxaparin after knee arthroplasty: randomized trial

BackgroundPharmacological and mechanical thromboprophylaxis are frequently used together after total knee arthroplasty (TKA). Most studies in this context compare anticoagulants versus a combination of these drugs with an intermittent pneumatic compression device (IPCD). However, there is uncertainty about the need for the combination of both and whether a unilateral IPCD would alone affect other important clinical outcomes: edema and blood loss. We compared the effects of enoxaparin versus unilateral portable IPCD after TKA on edema and blood loss. We hypothesised that unilateral IPCD would cause the same level of edema and the same blood loss as enoxaparin.MethodsIn this open, randomized trial (1:1), adults with no history of coagulation disorders, anticoagulant use, venous thromboembolism, liver or malignant diseases underwent TKA. For 10 days, participants received the IPCD, used 24 h/day on the operated leg from the end of surgery, or 40 mg of enoxaparin, starting 12 h after surgery. All underwent the same rehabilitation and were encouraged to walk on the same day of surgery. We measured edema (thigh, leg and ankle circumference) before and on the third postoperative day. Blood loss (volume accumulated in the suction drain and drop of hemoglobin and hematocrit in 48 h) was a secondary outcome.ResultsWe randomized 150 patients and lost 3 to follow-up with enoxaparin and 2 with IPCD. There was no case of symptomatic venous thromboembolism. Four patients needed transfusions (three receiving enoxaparin), one had infection and one hemarthrosis (both in the enoxaparin group). Leg circumference increased by approximately 2 cm for enoxaparin group and 1.5 cm in IPCD (p < 0.001). The increase in ankle circumference was about 1.5 cm in the enoxaparin group (p < 0.001), and almost zero in IPCD (p = 0.447). Enoxaparin group lost 566.1 ml (standard deviation, SD, 174.5) of blood in the first 48 h, versus 420.8 ml (SD 142.5) in the IPCD.ConclusionsExclusively mechanical prophylaxis after TKA with portable IPCD only on the operated leg reduces leg and ankle swelling and post-operative blood loss compared to exclusively pharmacological prophylaxis with enoxaparin. Portable devices that can prevent deep vein thrombosis and pulmonary embolism without increasing blood loss or other risks should be further investigated.Trial registrationREBEC RBR-8k2vpx. Registration date: 06/04/2019.

Adrenal Hemangioma Presenting as an Incidentaloma Clinically Suspicious for Malignancy

Abstract Introduction/Objective Adrenal hemangiomas are rare, benign and non-functioning tumors. Clinical diagnosis can be challenging given that the presentation is usually vague and lesions are often found incidentally during diagnostic imaging performed for other reasons. Methods/Case Report We report a case of a 67-year-old man with history of hypertension, hyperlipidemia, and anemia, arthralgia and joint swelling with unexplained weight loss, which prompted imaging studies. Computed tomography (CT) scan revealed a 5.4 cm mass involving the left adrenal gland. The patient had no clinical manifestations of adrenal medullary or cortical hyperfunction. Biochemical testing performed included urine and plasma metanephrines and aldosterone/renin ratio, which yielded results within normal range. The patient was taking prednisone for hand and ankle swelling, precluding assessment for Cushing’s syndrome. Given the size of the lesion, the possibility of malignancy was considered. The patient elected for a left adrenalectomy. Gross examination revealed a 4.9 cm mass, weighing 54 grams, with a tan-brown, congested cut surface and a thin rim of residual normal appearing adrenal gland parenchyma. Histologic examination of the surgical specimen showed an enlarged adrenal gland predominantly replaced by hemorrhage with foci of thick and thin walled vessels with areas of intermingled adrenocortical elements at the periphery. A diagnosis of adrenal hemangioma was made. Results (if a Case Study enter NA) NA. Conclusion Adrenal hemangioma should be considered in the differential diagnosis of adrenal tumors. Surgical resection is the mainstay of treatment for a large, isolated adrenal mass to exclude malignancy and prevent retroperitoneal hemorrhage.

Anethole ameliorates inflammation induced by monosodium urate in an acute gouty arthritis model via inhibiting TLRs/MyD88 pathway.

To assess the effects of anethole on monosodium urate (MSU)-induced inflammatory response, investigate its role in acute gouty arthritis (AGA), and verify its molecular mechanism. Hematoxylin and eosin staining assay and time-dependent detection of degree of ankle swelling were performed to assess the effects of anethole on joint injury in MSU-induced AGA mice. Enzyme-linked-immunosorbent serologic assay was performed to demonstrate the production levels of inflammatory factors (interleukin 1β [IL-1β], interleukin 6 [IL-6], interleukin 8 [IL-8], tumor necrosis factor α [TNF-α], and monocyte chemo-attractant protein-1 [MCP-1]) in MSU-induced AGA mice. Western blot assays were used to confirm the effects of anethole on oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome activity and the activation of toll-like receptors (TLRs)-myeloid differentiation factor 88 (MyD88) pathway in MSU-induced AGA mice. We observed that a significant joint injury occurred in MSU-induced AGA mice. Anethole could alleviate the pathological injury of the synovium in MSU-induced AGA mice and suppressed ankle swelling. In addition, we observed that anethole could inhibit MSU-induced inflammatory response and inflammasome activation in MSU-induced AGA mice. Moreover, we discovered that anethole enabled to inhibit the activation of TLRs/MyD88 pathway in MSU-induced AGA mice. Our findings further confirmed that anethole contributed to the inhibitory effects on progression in MSU-induced AGA mice. It confirmed that anethole ameliorated the MSU-induced inflammatory response in AGA mice in vivo via inhibiting TLRs-MyD88 pathway.

Anti-Inflammatory and Antioxidant Properties of Malapterurus electricus Skin Fish Methanolic Extract in Arthritic Rats: Therapeutic and Protective Effects

The protective and therapeutic anti-inflammatory and antioxidant potency of Malapterurus electricus (F. Malapteruridae) skin fish methanolic extract (FE) (300 mg/kg.b.wt/day for 7 days, orally) was tested in monosodium urate(MSU)-induced arthritic Wistar albino male rats’ joints. Serum uric acid, TNF-α, IL-1β, NF-𝜅B, MDA, GSH, catalase, SOD, and glutathione reductase levels were all measured. According to the findings, FE significantly reduced uric acid levels and ankle swelling in both protective and therapeutic groups. Furthermore, it has anti-inflammatory effects by downregulating inflammatory cytokines, primarily through decreased oxidative stress and increased antioxidant status. All the aforementioned lesions were significantly improved in protected and treated rats with FE, according to histopathological findings. iNOS immunostaining revealed that protected and treated arthritic rats with FE had weak positive immune-reactive cells. Phytochemical analysis revealed that FE was high in fatty and amino acids. The most abundant compounds were vaccenic (24.52%), 9-octadecenoic (11.66%), palmitic (34.66%), stearic acids (14.63%), glycine (0.813 mg/100 mg), and alanine (1.645 mg/100 mg). Extensive molecular modelling and dynamics simulation experiments revealed that compound 4 has the potential to target and inhibit COX isoforms with a higher affinity for COX-2. As a result, we contend that FE could be a promising protective and therapeutic option for arthritis, aiding in the prevention and progression of this chronic inflammatory disease.

The 4A classification for patients with tricuspid regurgitation

Abstract Background Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Clinical evaluation of TR patients is challenging. Purpose To establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its performance on prognosis. Methods Consecutive patients with isolated at least severe TR and absence of episodes of heart failure (HF) evaluated in the Heart Valve Clinic were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia where registered, follow up was performed every 6 months. 4A classification ranged from A0 (no A) to A4 (three or four A's present). A combined endpoint of hospital admission due to right HF and cardiovascular mortality was defined. Results 135 patients with significant TR between 2016 and 2021 were included (69% females, mean age was 78±7 years). During a median follow-up of 26 months (IQR: 10–41 months), n=53 patients (39%) reached the combined endpoint. 52 (38%) admitted for heart failure and 11% (n=15) died. At baseline 94% of patients were in NYHA I or II whereas 24% presented A2 or A3. The presence of A2 or A3 showed a high incidence of events (figure). The change in 4A class and GGT remained independent predictor of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class 1.95 [1.37–2.77], p&amp;lt;0.001) Conclusions For the first time, we show the use of a new clinical classification, specific for patients with TR based on signs and symptoms of right HF that is prognostic of events. Funding Acknowledgement Type of funding sources: None.

Primary care screening and prevention of heart failure coordinated by cardiologist in rural areas

Abstract Purpose Current guidelines do not support community-wide screening for undetected asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF), either with natriuretic peptides (NTproBNP) or open access echocardiography (echo). Universal access to NTproBNP testing (with reimbursement in primary care) before referral for tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 4376 consecutive patients (pts) were referred from January 2015 by general practitioners (GP) to echolab with suspected HF symptoms (unexplained breathlessness or ankle swelling). After confirmation elevated NTproBNP (&amp;gt;400 pg/mL) and MESA (Multi-Ethnic Study of Atherosclerosis) 5-year HF risk score ≥10 points and after exclusion significant valvular disease and abnormal electrocardiogram or chest x-ray in subgroup of randomly selected 829 asymptomatic elderly (≥65 years) pts (age 71±4 years, 48% women) with continued usual care by GP was compared with randomly selected 833 asymptomatic elderly pts from 5 GP practices in rural areas with prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 14% pts were treated with ACE-inhibitor (ACEi), 5% beta-blockers (BB) and 39% loop-diuretics. After cardiologist consultation loop-diuretics withdrawn in 90% pts, ACEi and BB use increased significantly to 98% and 82% in both groups (all p&amp;lt;0.001). Global LVSD (EF≤50%) was detected in 5% at baseline and 23% pts after 5 years in GP group, respectively 5.4% at baseline and 7% after 5 years in cardiologist group (p&amp;lt;0.001). Systolic dysfunction (S'≤6.0 cm/s) occurred in 14% at baseline and 38% pts after 5 years in GP group, respectively 15% at baseline and 21% after 5 years in cardiologist group (all p&amp;lt;0.001). Reduced global longitudinal (GLS&amp;lt;16%) observed in 20% at baseline and 51% pts after 5 years in GP group, respectively 21% at baseline and 29% after 5 years in cardiologist group (all p&amp;lt;0.001). At baseline we found 0.5% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54±4 months in cardiologist group developed new HF in 3% pts (1% HFmrEF, 2% HFpEF) compared with 19% pts (3% HFrEF, 7% HFmrEF, 9% HFpEF) in GP group (p&amp;lt;0.001). Significant (p&amp;lt;0.001) predictors of incident HFmrEF were systolic dysfunction (S'≤6.0 cm/s), hazard ratio (HR) 2.2, 95% CI 1.82–2.9) and reduced GLS (HR 3.5, 95% CI 3.1–3.9), all p&amp;lt;0.01. The strongest (p&amp;lt;0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 1.9, 95% CI 0.9–3.9) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.52, 95% CI 1.22–1.89), all p&amp;lt;0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between GP and specialised HF outpatient clinic. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grant from the Slovak Society of Cardiology 2015 Selective screening of heart failure stages in regional settings

Epithelioid malignant peripheral nerve sheath tumor: A rare tumor with an unusual presentation in the ankle: A case report and literature review

Malignant peripheral nerve sheath tumor (MPNST) is a rare sarcoma with aggressive clinical zehavior. Epithelioid MPNSTs (EMPNSTs) are distinct and rare variant of MPNST. They are described by the World Health Organization and they account for &lt;5% of these tumors and have unclear clinical behavior. Due to the rarity of the EMPNST and the overlapping features and similarity with other tumors exhibiting epithelioid cytomorphology, EMPNSTs impose a diagnostic challenge. Therefore, it is critical to be aware of this entity and other mimickers to reach the correct diagnosis. Hence, this is a case of a 45-year-old lady who presented with persistent left ankle swelling for 2 years. A biopsy was performed, which confirmed the diagnosis of EMPNST. The aim of reporting this case of this rare tumor with this presentation was to help both pathologists and orthopedic oncology surgeons to understand the behavior of this tumor and help differentiate it from mimickers, and enrich interested readers’ knowledge with the presented literature review.

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

Accessory Soleus: Posterior Ankle Pain in Two Adolescent Athletes

Category: Sports Introduction/Purpose: Accessory soleus muscles are a rare cause of posterior ankle pain and swelling in adolescent athletes. The increased accessibility of MRI imaging has been a helpful aid its proper diagnosis and treatment. Different surgical treatment also exists including partial fasciotomy as well as surgical excision. This case report offers 2 cases of adolescent athletes with this finding causing pain and swelling in the posterior ankle limiting rigorous athletic activities that were treated with surgical excision of the accessory soleus. Methods: Two patients were evaluated in clinic for posterior ankle pain during participation in rigorous athletic activities. The first patient was a 13-year-old girl with posterior ankle pain and swelling while playing softball that limited her ability to pitch more than one inning. The second patient was a 17-year-old boy with posterior ankle pain and swelling that limited his ability to perform at peak performance during basketball games. Both patients had MRI evaluation of the ankles after months of no improvement with nonoperative treatment. MRI demonstrated accessory soleus muscles that was attributed to be the cause of their symptoms. After unsatisfactory symptom relief with nonoperative treatment measures, the two patients underwent surgical excision of the accessory soleus muscle. Results: Both patients underwent surgical excision of the accessory soleus muscle through a posteromedial approach. The accessory soleus muscle was found just anterior and medial to the Achilles tendon. The muscle was detached from its insertion into the calcaneus distally and traced back proximally. The muscle was then truncated proximally approximately 5-6 cm proximal to its insertion on the calcaneus. Both patients began weight bearing to tolerance in a walking boot immediately postoperatively. Both patients experienced resolution of their symptoms after surgical excision. Conclusion: Accessory soleus muscles are rare anomalous muscles of the posterior ankle that can cause pain and swelling with activity. Increased accessibility of MRI imaging has led to its diagnosis and treatment. Surgical excision is a reasonable surgical treatment option when nonoperative treatment fails to alleviate symptoms.

P207 A rare case of disseminated Blastomycosis in an immunocompetent host: A report from North India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectivesBlastomycosis is a serious life-threatening systemic infection caused by dimorphic fungi Blastomyces dermatitidis. Infection is acquired via inhalation of airborne conidia or traumatic inoculation. It may produce a spectrum of infections ranging from asymptomatic infections in immunocompetent patients to disseminated disease, including skin, bone, genitourinary tract, and central nervous system (CNS) involvement in immunocompromised patients. This fungal infection is very rare in India. We report a unique case of disseminated blastomycosis in an immunocompetent patient.MethodsA 37-year-old male patient from Kanpur, Uttar Pradesh presented with chief complaints of hematuria associated with passage of blood clots for 3 months. There was no history of dysuria, fever, or pain abdomen. When he was evaluated for gross hematuria, his USG abdomen was suggestive of bilateral renal masses. To rule out bilateral renal cell carcinoma an FDG pet scan was done which was suggestive of FDG avid lesions in the bilateral kidneys. He also had enlarged left supraclavicular and left cervical lymph nodes. Multiple nodular and verrucous lesions were seen all over the face. He complained of pain in the left ankle; with a small wound opening on the medial malleolus of the left ankle.ResultsA skin biopsy was taken from one of the nodular and verrucous lesions over face. A total of 10% wet mount KOH preparation shows no epithelial cells, plenty of pus cells, no RBCs, and plenty of thick-walled round yeasts and some with broad-based budding yeasts (8-12 microns) suggestive of Blastomyces species. Renal abscess pus FNAC, left cervical lymph node, and CT-guided biopsy from the medial malleolus of the left ankle also showed similar round yeasts and some with broad-based budding suggestive of Blastomyces species. Hence, a preliminary diagnosis of disseminated blastomycosis was made.Cultures were put in SDA at 25°C and 37°C and after a week, colonies appeared as fluffy white glabrous with reverse cream-colored non-sporulating colony. On day 25, colony appears as tan glabrous fluffy with brownish reverse with sporulation. LPCB was done from the colony which showed thin septate hyphae with pedunculated and sessile spherical to pyriform and smooth walled microconidia suggestive of Blastomyces dermatitidis.He was started on IV liposomal amphotericin B for 20 days. HCV RNA was detected incidentally and he had transaminitis therefore, he could not be started on itraconazole, he was started on fluconazole. His facial lesions cleared dramatically; his left ankle pain and swelling had resolved. At present, he was symptomatically better and was discharged on 200 mg fluconazole once daily and advised for follow-up after 2 weeks.ConclusionBlastomycosis is a relatively uncommon geographically restricted chronic granulomatous disease that mainly occurs in the endemic regions. This fungus lives primarily in moist soil and decomposing matter, and inhabits the mid-west, south-central, southeastern United States as well as the boreal forests of Ontario and Quebec in Canada. Very little is known about the natural habitat and environmental distribution of Blastomyces species in India. This case is unique because the patient is immunocompetent and has no history of travel outside of India.

Conduction Velocity of Spinal Reflex in Patients with Acute Lateral Ankle Sprain.

Recent literature has highlighted altered spinal-reflex excitability following acute lateral ankle sprain (ALAS), yet there is little information on the conduction velocity of spinal reflex pathways (CV-SRP) in these patients. Therefore, we aimed to investigate the effects of ALAS on the CV-SRP. We employed a cross-sectional study with two groups: ALAS (n = 30) and healthy controls (n = 30). The CV-SRP of the soleus, fibularis longus, and tibialis anterior was assessed using the H-index method. As secondary outcomes, H-reflex and M-wave latencies were assessed as well as acute symptoms including ankle swelling, pain, and self-reported ankle function. Separate group-by-limb ANOVA with repeated measures revealed a significant interaction for soleus CV-SRP (p < 0.001) and H-reflex latency (p < 0.001), showing significant slower CV-SRP and longer H-reflex latency in the involved limb of the ALAS group compared with both limbs in the control group. However, there was no significant interaction or main effect in any other ankle muscles (p > 0.05). A further correlation analysis showed a significant relationship between CV-SRP and acute symptoms, including ankle swelling (r = −0.37, p = 0.048) and self-reported ankle function (r = 0.44, p = 0.017) in ALAS patients. These results suggest a disrupted functionality of the afferent pathway and/or synaptic transmission following ALAS. Level of Evidence: 4.

Traditional Chinese Medicine Rhodiola Sachalinensis Borissova from Baekdu Mountain (RsBBM) for Rheumatoid Arthritis: Therapeutic Effect and Underlying Molecular Mechanisms.

The lack of effective rheumatoid arthritis (RA) therapies is a persistent challenge worldwide, prompting researchers to urgently evaluate traditional Chinese medicines (TCMs) as potential clinical RA treatments. The present investigation was conducted to evaluate the therapeutic effects and potential molecular mechanisms of the active components isolated from TCM Rhodiola sachalinensis Borissova from Baekdu Mountain (RsBBM) using an experimental adjuvant arthritis model induced by injection of rats with Freund’s complete adjuvant. After induction of the adjuvant arthritis rat model, the extract-treated and untreated groups of arthritic rats were evaluated for RsBBM therapeutic effects based on comparisons of ankle circumferences and ELISA-determined blood serum inflammatory factor levels (TNF-α, IL-1β, and PGE2). In addition, the joint health of rats was evaluated via microscopic examination of hematoxylin-eosin-stained synovial tissues. Furthermore, to explore whether NF-κB and RANK/RANKL/OPG signaling pathways participated in observed therapeutic effects from a molecular mechanistic viewpoint, mRNA and protein levels related to the expression of nuclear factor kappa-B (NF-κB), osteoprotegerin (OPG), and receptor activator of nuclear factor kappa-Β ligand (RANKL) were analyzed via quantitative RT-PCR and Western blot analysis, respectively. Treatment of arthritic rats with the extract of RsBBM was shown to reduce ankle swelling, reduce blood serum levels of inflammatory factors, and alleviate arthritis-associated synovial inflammation and joint damage. Moreover, an RsBBM 50% ethanol extract treatment inhibited bone destruction by up-regulating OPG-related mRNA and protein expression and down-regulating RANKL-related mRNA and protein expression, while also reducing inflammation by the down-regulating of the NF-κB pathway activity. The results clearly demonstrated that the extract of RsBBM alleviated adjuvant arthritis-associated joint damage by altering activities of inflammation-associated NF-κB and the RANK/RANKL/OPG signaling pathways. Due to its beneficial effects for alleviating adjuvant arthritis, this RsBBM 50% ethanol extract should be further evaluated as a promising new therapeutic TCM treatment for RA.

Cytological findings of rhizomelic chondrodysplasia punctata: A rare skeletal dysplasia

Chondrodysplasia punctata (CDP) is a rare, skeletal dysplasia characterized by stippled, punctuate calcifications around joints and within cartilages. A 4 months old female infant presented to us for aspiration cytology with clinical suspicion of sarcoma due to complaint of ankle swelling and failure to thrive. Fine needle aspiration (FNA) smears were acellular with only calcific deposits. On clinical co-relation depressed nose and frontal bossing were noted. We suspected it to be a case of congenital skeletal dysplasia. Plain X-ray of the lesion was ordered and it revealed stippled calcification in place of ankle bones consistent with chondrodysplasia punctata. The present case is an index case describing the cytology of chondrodysplasia punctata. CDP is mainly a radiologically diagnosed lesion, however the knowledge of its cytological picture through this case will make pathologists alike aware if they encounter such case. The management is basically supportive and rehabilitative.

Anterior Talofibular Ligament All-Inside Arthroscopic Reconstruction with InternalBrace™ for Chronic Lateral Ankle Instability.

BackgroundAnterior talofibular ligament (ATFL) is the most easily injured or even broken of ankle sprain. Patients who fail to receive conservative treatment, resulting in persistent ankle swelling, painful and functional decline that it is so-called chronic lateral ankle instability (CLAI). It makes sense to investigate all-inside arthroscopic reconstruction of ATFL with InternalBrace™ for CLAI.Material/MethodsWe included 108 patients who underwent all-inside arthroscopic ATFL reconstruction with InternalBrace™ for CLAI from January 2018 to April 2020 through a retrospective study. Patients age ranged from 19 to 58 years (mean 35.6±8.7 years). Several elements are used to evaluate the clinical consequences of ankle function, including the American Orthopedic Foot and Ankle Society (AOFAS), Japanese Society for Surgery of the Foot Ankle-Hindfoot (JSSF), Kofoed, Tegner scores and complications, and the tilt angle of talus (TT) and the anterior displacement of talus (ADT) with stressing radiographs were taken to measure in follow-ups.ResultsAll 108 patients had all-inside arthroscopic procedures performed smoothly without serious complications. During the follow-up period (26.7±2.6 months on average), no recurrence of ankle instability and other serious complications happened. The AOFAS, JSSF, Kofoed, and Tegner scores significantly increased as time went by postoperatively, which proved statistically significant (P<0.01). Regarding stress-radiographic measurements, TT significantly decreased from (9.5±1.1)° preoperatively to (2.6±0.6)° at the latest follow-up (P<0.01), while ADT significantly decreased from (9.5±1.0) mm preoperatively to (2.6±0.6) mm at the latest examination (P<0.01).ConclusionsAll-inside arthroscopic ATFL reconstruction with the InternalBrace™ for CLAI is beneficial for ankle stability, allowing earlier return to activities.

Knee And Ankle Swelling—Daily Walker

HISTORY: A 68-year-old woman who walks daily presented to sports medicine clinic with left ankle and knee pain and swelling. Her pain started three weeks prior to presentation in her left ankle followed by redness and swelling. Several days later her left knee became painful, swollen, and red. She was unable to participate in her daily walks, and the pain started to wake her from sleep. The pain was described as achy and stiff. She had tried treatment with Naproxen and Tylenol without relief. No known injuries or tick bites. She denied fevers, previous joint pain, rash, or rheumatologic history. Several days before the onset of her joint pain she was seen in the emergency department for diarrhea. PHYSICAL EXAM: She was afebrile with a nontoxic appearance with significant joint effusions of the left knee and ankle with erythema. Diffuse tenderness to palpation over both joints. Range of motion of the ankle and knee were limited by effusions and pain. Strength was 5/5 with knee flexion/ extension, ankle dorsiflexion/ plantar flexion. Ligamentous and meniscal exams were limited by pain. Her gait was antalgic. DIFFERENTIAL: 1. Lyme or tick related illness 2. Reactive arthritis 3. Rheumatic arthritis 4. Gout/ pseudogout 5. Septic arthritis TEST AND RESULTS: X-ray of her left ankle obtained prior to her appointment showed an effusion. Blood work was notable for: negative tick-borne Ab panel. Elevated ESR (81), and CRP (9.9). Uric acid within normal limits. CBC with mildly elevated WBCs. CMP unremarkable. HLA B27 Positive. CCP antibodies and RF negative. Left knee joint aspirate was obtained via ultrasound guidance, and notable for: negative tick-borne PCR and crystals. Uric acid within normal limits. Smear: 3+ polymorphonuclear white blood cells. Culture with no growth. Stool cultures returned positive for Salmonella Enteritidis FINAL/ WORKING DIAGNOSIS: Salmonella Enteritidis reactive arthritis. TREATMENT AND OUTCOMES: Patient was seen by rheumatology where 40 mg prednisone daily was started for treatment of reactive arthritis with improvement in her pain within days. She had a prolonged treatment course due to viral infections that required intermittent discontinuation of her prednisone treatment. At an appointment after prednisone was completed, she had resolution of the effusions, and was able to walk pain-free.