Lower Extremity Swelling Research Articles

Great saphenous vein suppurative thrombophlebitis due to Fusobacterium necrophorum infection

Abstract Fusobacterium necrophorum (F. necrophorum) is an anaerobic Gram-negative bacterium which does not form spores. F. necrophorum is usually associated with Lemierre's syndrome. The syndrome is characterized by thrombosis of the internal jugular vein with septicemia followed by oropharyngeal infection. In the present case report, a 27-year-old male with a significant medical history of intravenous drug use was presented in the emergency department. The patient presented a 3-day history of left lower extremity pain, redness, and swelling. His serological tests were positive for hepatitis C infection. The Duplex ultrasound (US) of the left lower extremity revealed extensive suppurative thrombophlebitis. The blood culture grew F. necrophorum, thus the patient was treated with IV ampicillin for 2 weeks, followed by additional 2 weeks of oral amoxicillin. At follow-up, 3 weeks later, the patient reported significant improvement in his symptoms. Three months later, lower extremity duplex in the US revealed resolving suppurative thrombophlebitis.

Hydatid cyst of the liver fistulized into the inferior vena cava.

IntroductionFistulization or rupture of hydatid liver cysts to the inferior vena cava (IVC) is an extremely rare and life-threatening condition.Presentation of caseWe report the case of a 70-year-old patient who presented with right-upper-quadrant pain and fullness evolving for 03 months. Physical examination showed dilated veins over the anterior abdominal wall and the flanks associated with lower-extremity swelling. Computed tomograph of the abdomen showed a hydatid cyst invading segments VI and VII of the liver fistulized into the inferior vena cava. The IVC was partially trombosed. The diagnosis of a possibly ruptured hydatid cyst in the inferior vena cava was then made. The patient underwent surgical management. Per-operatively the cystic cavity had bloody content but the cysto-vascular communication was not identified. Partial cystectomy was performed leaving a fairly extensive contact between the calcified pericyst and the IVC. The postoperative course was uneventful.DiscussionRupture of the hepatic hydatid cyst into the IVC is very rare and may lead to fatal pulmonary embolism secondary to the migration of vesicles in the pulmonary artery or haemorrhagic shock. CT scan remains the best investigation method to assess the vascular links of the hepatic hydatid cyst especially with the IVC. Surgical treatment of the hepatic hydatid cyst ruptured into the IVC mandates vascular control before the hydatid cyst is punctured or removed.ConclusionFistulized hydatid cysts into the IVC should be operated on in centres equipped for extracorporeal bypass techniques, and experienced in the surgery of hepatic echinococcosis.

Editor's Choice – Clinical Efficacy of Venastent - A Novel Iliac Vein Stent for Non-Thrombotic Iliac Vein Lesions: A Multi-Centre Randomised Controlled Trial

To determine the efficacy of Venastent - a novel iliac vein stent for non-thrombotic iliac vein lesions (NIVLs). From October 2018 to January 2021, 256 NIVL patients were recruited at 19 Chinese hospitals. A randomised controlled trial was conducted to compare the efficacy of the new iliac vein stent-Venastent (Tianhong China) with Zilver stent (Cook USA). All patients were allocated randomly to two groups: the experimental group patients used Venastent, while the control group received the Zilver stent. The trial was registered in Chinese Clinical Trial Registry (ChiCTR2200057851). A total of 123 patients in the experimental group and 122 patients in the control group had a full set of data collected (p= ns). The technical success rate was 100% (n= 245/245). The patency rate was 100% (n= 123/123) in the experimental group and 98.4% (n= 120/122) in control group one year after operation (p= ns). The lower extremity swelling remission rate was 79.1% (n= 87/110) in the experimental group and 78.4% (n= 91/116) in the control group (p= ns). The lower extremity pain relief rate was 68.8% (n= 50/80) in the experimental group and 77.2% (n= 71/92) in the control group (p= ns). The ulcer healing rate was 90% (n= 18/20) in the experimental group and 87% (n= 20/23) in the control group (p= ns). There was no difference in stent re-stenosis or clinical remission between the two groups. The new iliac vein stent, Venastent, had a comparable high patency rate and safety profile as the Zilver stent (Cook) in NIVLs patients. Venastent significantly reduced symptoms of chronic venous disease.

Charles Procedure for Elephantiasis in Lower Extremity: A Rare Case Report from Sanglah Hospital

Background: Elephantiasis is damage of the lymphatic vessels or destruction of lymph nodes that caused by filariasis infection. It was chronic and slowly progressive disease which decrease function and quality of life. There are two alternative approaches for surgery: reconstructive surgery and destructive surgery. The treatment aims to restore function, reduce physical and psychological suffering, and prevent the complication growth. Method: In this case report, a 43 years old male presented left lower extremity swelling. Based on clinical examination and investigation the patient was diagnosed with elephantiasis of lower extremity and a surgery will be done by Charles procedure. Result: This paper reported a successful Charles Procedure for elephantiasis of lower extremity. Due to the large mass of the tissue, our case was done by two-stage. After healthy granulation tissue is achieved, we planned to do skin grafting. Conclusion: Charles procedure is recommended for elephantiasis and can be adjuvant treatment. Although postoperative complication may occur, with the correct multidisciplinary support, significant improvements in function and quality of life can be achieved.

Isolated Right Heart Failure and Tricuspid Regurgitation in a Patient with Untreated Hyperthyroidism: A Case Report

Introduction: Hyperthyroidism has been known to cause a variety of cardiovascular manifestations. Isolated right heart failure (RHF) occurs occasionally, is usually due to pulmonary hypertension or tricuspid valve abnormalities. In rare cases, hyperthyroidism could be the underlying disease. Case Presentation: A 72-year-old woman with suspected but untreated hyperthyroidism presented with progressive dyspnea and lower extremity swelling in the last ten days. Physical examination showed an irregular and high heart rate, increase in JVP, enlargement of the thyroid gland, systolic murmur, and clear lungs. The laboratory findings showed an elevated level of free T4 (2.51 ng/dL) and a low level of TSH (<0.003 uIU/mL). Electrocardiogram revealed atrial fibrillation with a rapid ventricular response. Echocardiography showed right atrial and right ventricular dilatation with moderate tricuspid regurgitation. Left ventricular size and systolic function were normal. Chest x-ray showed a cardiothoracic ratio of 53% with organized left pleural effusion. Symptoms resolved as her thyroid hormone levels normalized with adequate treatment. Discussion: The most common changes that result from hyperthyroidism to the cardiovascular system are increased cardiac preload, decreased peripheral vascular resistance, direct injury, increased heart rate and contractility, which together produce a hyper dynamic circulatory state that leads to increased blood volume and venous return resulting in the increased risk of RHF. Conclusion: Hyperthyroidism is a potentially reversible cause of heart failure and should be ruled out in every heart failure patient, especially in those with isolated right heart failure, tricuspid regurgitation, and pulmonary hypertension. These conditions can potentially be well managed with adequate treatment.

Establishment of Prediction Models for Venous Thromboembolism in Non-Oncological Urological Inpatients - A Single-Center Experience.

PurposeVenous thromboembolism (VTE) comprises deep venous thrombosis (DVT) and pulmonary embolism (PE), which can lead to death. VTE is an insidious disease with no specific symptoms and overlooked readily. We aimed to establish prediction models for VTE in non-oncological urological inpatients to aid urologists to better identify VTE patients.Patients and MethodsA retrospective analysis of 1453 inpatients was carried out. The risk factors for VTE had been clarified in our previous study. A stepwise regression method was used to screen the relevant influencing factors for VTE and construct a logistic regression prediction model to predict VTE. To validate the accuracy of the model, data from 291 patients from another cohort were used for external validation.ResultsA total of 1453 inpatients were enrolled. Five potential risk factors (previous VTE; treatment with anticoagulants or anti-platelet agents before hospital admission; D-dimer ≥0.89 μg/mL; lower-extremity swelling; chest symptoms) were selected by multivariable analysis with p < 0.05. These five risk factors were used to build a logistic regression prediction model. When p < 0.1 in the multivariable logistic regression model, two additional risk factors were added: Caprini score ≥5 and complications, and all seven risk factors were used to build another prediction model. Internal verification showed the cutoff values, sensitivity, and specificity of the two models to be 0.02474, 0.941, 0.816 (model 1) and 0.03824, 0.941, and 0.820 (model 2), respectively. Both models had good predictive ability, but prediction accuracy was 43.0% for both when using the data of the additional 291 inpatients in the two models.ConclusionTwo novel prediction models were built to predict VTE in non-oncological urological inpatients. This is a new method for VTE screening, and internal validation showed a good performance. External validation results were suboptimal but may provide clues for subsequent VTE screening.

Painless Presentation of a Deadly Disease: Type A Aortic Dissection Requiring the Bentall Procedure.

Aortic dissection is a relatively uncommon, although catastrophic, disease which requires early and accurate diagnosis and treatment for patient survival. Aortic dissection can be difficult to diagnose due to the diverse symptom presentation, which can lead to later diagnosis, resulting in a higher mortality rate. Here we present a case of type A aortic dissection with a varied symptom presentation, highlighting the importance of early detection and the Bentall procedure for management of such cases. A 50-year-old man with no known medical history presented with bilateral lower extremity swelling and fatigue for 2 weeks. The patient denied any chest pain or dyspnoea. Vital signs showed blood pressure of 160/76 mmHg, pulse of 103 bpm, respiratory rate of 18, and temperature of 36.7°C. Laboratory findings indicated a BNP of 1901 pg/ml and troponin of 0.5 ng/ml. An initial diagnosis of decompensated heart failure was made, and IV Lasix was started. Subsequently, an echocardiogram indicated an EF of 50–55% and ascending dissection of the aorta. A CT angiogram of the chest and abdomen confirmed this diagnosis. This patient presented with unusual symptoms of aortic dissection without the typical presentation of chest pain. It is important to consider aortic dissection in a cardiac-related case as prompt imaging can help confirm the diagnosis. We explore the risks and benefits of the Bentall procedure for the management and early detection of aortic dissection.LEARNING POINTSThe absence of chest pain does not rule out aortic dissection as 50% of patients are pain free.It is critical to diagnose aortic dissection early in the disease course as mortality increases by 1% per hour from symptom onset.The aim of this study is also to raise awareness among healthcare professionals about the Bentall procedure in patients with type A aortic dissection involving the aortic valve.

Risk factors for lower extremity lymphedema after inguinal lymphadenectomy in melanoma patients: A retrospective cohort study

BackgroundThe aim of lymph node dissection for melanoma patients is to prevent metastasis. However, this procedure is accompanied by a long-term and impaired life-quality complication called extremity lymphedema. This condition involves long-term lower limb swelling, which causes discomfort and impaired function, and affects patients both physically and psychologically. Herein, we conducted a retrospective cohort study at a single center to investigate the risk factors associated with lower extremity lymphedema after inguinal lymphadenectomy. Materials and MethodsWe identified 136 inguinal lymphadenectomy melanoma patients treated between January 2010 and January 2021. The patients' demographic, clinical, and pathological data and postoperative outcomes were collected by electronic medical record review and patient follow-up. The patients' postoperative outcomes were defined as lower extremity swelling and lower extremity lymphedema. Univariate and multivariate analyses were used to determine the independent predictors of lower extremity lymphedema. ResultsThe follow-up results from 85 melanoma patients who underwent inguinal lymphadenectomy were analyzed. Multivariate logistic regression analysis showed that number of lymph nodes removed≥10 was the significant risk factor for postoperative lower extremity lymphedema (odds ratio = 6.468, P = .042, 95% confidence interval: 1.069 to 39.147). Moreover, 8 (100%) patients in the lower extremity lymphedema group and 32 (53.3%) patients in the normal group were female, which indicated that female patients might be more susceptible to postoperative lower extremity lymphedema (P = .012). ConclusionOur study found that number of inguinal lymph nodes removed ≥10 was associated with a significantly higher incidence of lower extremity lymphedema with a 6.5-fold increased risk in melanoma patients. Also, female patients were more likely to develop lower extremity lymphedema after inguinal lymphadenectomy.

A Human Space.

A Human Space.

Diabetic Foot Infection Caused by Pasteurella Multicide: A Case Report and Review of The Literature

Pasteurella multicide is the most common cause of human soft tissue infection, usually associated with domestic animals contact history. Reports of diabetic foot infections caused by Pasteurella multicide without contact history are rare. Here we report the case of a 51-year-old man with diabetic foot infection who was cured with penicillin. A variety of antibiotics were replaced after admission, his body temperature and right lower extremity swelling had not improved, and symptoms such as heart failure, anemia and renal insufficiency occurred. Finally, Pasteurella multicide was detected by next-generation sequencing and he got better after the use of penicillin. In Non-contact cases, diabetic foot infection caused by Pasteurella multicide may be related to impaired immunity.

A rare case of renal infarction due to heroin and amphetamine abuse: case report

BackgroundRenal infarctions as a result of recreational drug use are rare and are commonly associated with cocaine use. Although amphetamines have a similar mechanism of action as cocaine, there are few reports linking them to ischemic events, and only one to renal infarction. Similarly, few reports link heroin use with infarcts, but never in the kidney. Although uncommon, several mechanisms have been implicated in heroin and amphetamine-induced infarction, including vasculopathy, vasculitis and the activation of the coagulation cascade.Case Presentation47-year-old female with a past medical history of non-intravenous heroin and amphetamine abuse, chronic obstructive pulmonary disease, hypertension, hyperlipidemia presented with right lower extremity swelling and rash, which was diagnosed as cellulitis and treated appropriately. Incidentally, the patient was found to have an acute kidney injury and further workup identified multiple renal infarcts in the right kidney. The patient had no past medical history of clotting disorders. Blood culture and urine cultures were sterile; autoimmune and hypercoagulable workup were negative. Urinalysis was unremarkable. Urine toxicology was only positive for opiates and amphetamines, which were thought to be the most likely cause of the renal infarct. Patient was lost to outpatient follow up due to noncompliance, but returned to the hospital for re-emergence of her cellulitis, during which no new infarcts were discovered, and the previous renal infarct had scarred over.ConclusionThere are very few reports of heroin and amphetamine-induced infarctions. This case report describes a rare but important complication of heroin/amphetamine abuse that could be easily overlooked.

Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis

A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet. The patient was anemic (hemoglobin of 8.0 g/dL) and had renal insufficiency (serum creatinine concentration of 1.66 mg/dL). Leukocytosis was present (11.8 103/µL). The plasma brain natriuretic peptide level was markedly elevated (20,063 pg/mL). An increase in high-sensitivity troponin concentration also was observed. An electrocardiogram revealed sinus tachycardia and low-voltage QRS complexes, but acute ST-segment changes were absent. Transthoracic echocardiogram revealed vegetations on both the aortic and mitral valves, resulting in severe regurgitation. Transesophageal echocardiography (TEE) also was performed as part of the diagnostic evaluation, and the following images were obtained (Fig. 1-3; Videos 1-3). What is the diagnosis?

All in the Family: A Curious Case of Aortopathy

A 28-year-old African American male with history of intermittent headaches presented to an outside hospital (OSH) with few days history of severe right lower extremity pain, swelling and dyspnea. Lower extremity venous ultrasound revealed a large occlusive deep vein thrombosis (DVT) extending from the right common femoral to the right popliteal vein. Chest Computed tomography angiogram (CT Angiogram) revealed a 5.9 cm mid ascending thoracic aortic aneurysm, a 3.2 cm pulmonary artery dilatation and no evidence of pulmonary embolus. He was started on anticoagulation with intravenous heparin and transferred to our institution for surgical management of the aortic aneurysm and evaluation for large vessel vasculitis.

A Life-Changing Diagnosis of Focal Segmental Glomerulosclerosis in a Young Hispanic Male

Focal segmental glomerulosclerosis is a nephrotic syndrome characterized by significant proteinuria on urinalysis and sclerosis in parts of at least one glomerulus on biopsy. While primary cases are on the rise over the past two decades, it is important to rule out etiologies that cause secondary focal segmental glomerulosclerosis such as HIV and Hepatitis B. The prevalence of this disease over the past few decades has been notably higher in men and in particular African Americans. Here, we discuss a case of a 25-year-old Hispanic man who was found to have focal segmental glomerulosclerosis after initially presenting with facial and upper and lower extremity swelling.

Clinical Images: Spotted bone: Incidental detection of a rare genetic disease.

The patient, a 27-year-old woman with a history of Hashimoto thyroiditis, presented to the rheumatology clinic for upper and lower extremity swelling. A physical examination demonstrated hand swelling and flesh-colored lichenified papules on her sacrum, neck, and ankles. Results of laboratory workup showed weakly positive antinuclear antibodies (1:320) with a nuclear fine-speckled pattern but otherwise no autoantibodies. A skin biopsy specimen demonstrated thickened dermal collagen consistent with connective tissue nevus. We obtained anterior–posterior (AP), axial, and Grashey views on radiographs of both shoulders (A); AP, lateral, and oblique radiographs of both feet (B); and posterior–anterior, lateral, and oblique radiographs of both hands (C). Each view demonstrated diffusely distributed small sclerotic densities overlying the normal osseous structures consistent with scattered enostoses. The differential diagnosis included sclerosing bony dysplasias (sporadic or inherited), sclerotic metastases, osteomas, and osteosarcomas (1). Genetic testing revealed a heterozygous mutation in LEMD3. Her constellation of findings was consistent with Buschke-Ollendorff syndrome, an autosomal dominant condition in which diagnostic features include osteopoikilosis, connective tissue nevi, an LEMD3 mutation, and a family history (2). Loss-of-function mutations in LEMD3, a gene involved in bone morphogenic protein signaling, have been previously described in cases of Buschke-Ollendorff syndrome, although the exact relationship is yet unknown (3). Imaging features that may help differentiate osteopoikilosis from other malignant disorders include its preponderance for the epiphyseal regions of short tubular bones, lesion size less than 1 cm, homogenously radiodense lesions with spiculated margins, and lack of uptake on bone scintigraphy (1, 4). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Associated with Enoxaparin Therapy in a Pediatric Patient

Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a rare drug hypersensitivity reaction characterized by diffuse skin eruption with systemic symptoms (fever, lymphadenopathy, elevated transaminases, leukocytosis with eosinophilia and atypical lymphocytes) which develops 2-6 weeks after exposure to inciting medications. Clinical presentation is variable and nonspecific. DRESS syndrome is more common in adults, can be life threatening, and is most commonly seen with antibiotics, antiepileptic drugs, and allopurinol. An inciting drug is identified in the majority of cases. DRESS syndrome has been described rarely in association with Vitamin K antagonists and direct oral anticoagulants. In an in-depth examination of existing literature, there are only two reported cases of DRESS syndrome associated with enoxaparin therapy, both in adult patients and no reports of pediatric DRESS syndrome secondary to anticoagulants. We present a case of a pediatric patient with DRESS syndrome associated with enoxaparin therapy.Case Report: A previously healthy 11-year-old female was admitted with sepsis secondary to osteomyelitis and periosteal abscess of the left lower extremity, as well as MRSA bacteremia. The patient was initiated on clindamycin and vancomycin for treatment of underlying infections. A left lower extremity ultrasound with doppler was obtained due to lower extremity swelling and demonstrated an acute deep venous thrombus of the left popliteal vein. She was initiated on a heparin drip and subsequently transitioned to enoxaparin one week later. Several weeks into her hospital course (two weeks after initiation of enoxaparin), she developed facial swelling, a generalized morbilliform rash, and diffuse lymphadenopathy both on exam and abdominal imaging. She continued to have persistent fevers despite multiple washouts of the extremity, appropriate antimicrobial coverage, and negative blood cultures. Liver enzymes concurrently increased (AST 362 IU/L (normal 5-60 IU/L), ALT 371IU/L (normal <35 IU/L) at peak) with development of clinical symptoms. Eosinophilia was not present on initial CBC, though she subsequently developed mild eosinophilia (1.1 K/ul at peak). HHV6, CMV, and EBV serologies were all negative. Skin biopsy was performed and was consistent with a drug eruption. Using the RegiSCAR criteria for DRESS syndrome, this constellation of labs and symptoms indicate a definite case of DRESS syndrome with a score of 6 (final score >5 is needed for a definite case). The patient was started on treatment with high-dose steroids. Clindamycin and vancomycin were both discontinued due to their known association with DRESS syndrome. She was transitioned to doxycycline, however, no improvement in rash, fevers, or liver enzymes was seen over the course of five days. Given this, enoxaparin was transitioned to apixaban. The patient improved with resolution of rash, fevers, and improvement of liver enzymes and eosinophilia within a few days of the discontinuation of enoxaparin.Conclusion: The diagnosis of DRESS syndrome can be challenging due to its nonspecific presentation, particularly in pediatric patients where symptoms can overlap with common viral syndromes and Kawasaki disease, and therefore requires a high index of suspicion. Though children with DRESS syndrome have a better prognosis than adults, prompt recognition and treatment is required to limit morbidity and mortality. In pediatric patients receiving treatment with enoxaparin, DRESS syndrome should be included on the differential for those who develop persistent fevers, lymphadenopathy, rash, transaminitis and/or eosinophilia, and discontinuation of enoxaparin should be considered. DisclosuresWeyand: Takeda: Consultancy; Genentech: Consultancy; Novo Nordisk: Research Funding; Sanofi: Consultancy, Research Funding.

Intrapelvic Pseudotumor Causing Neuropathy and Vascular Obstruction After Revision Total Hip Arthroplasty: A Case Report

Background: There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood. Methods: We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention. Results: Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films. Discussion and Conclusion: This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.

Treatment-resistant venous thrombosis and pulmonary embolism in a patient with granulomatosis with polyangiitis: a case report

BackgroundWe herein present a case of venous thrombosis that developed more than 20 years after diagnosis of granulomatosis with polyangiitis (GPA), although many reports of GPA have described venous thrombosis within 1 year of diagnosis.Case presentationA 73-year-old man with GPA was admitted for lower extremity swelling and diagnosed with venous thrombosis and pulmonary embolism. On the second day, catheter-based thrombolysis was unsuccessful, and inferior vena cava filter insertion and anticoagulation were performed. On the third day, respiratory disturbance and loss of consciousness appeared and progressed. The patient died on the fifth day. The autopsy revealed a large thrombus in the inferior vena cava filter, and death of progressive venous thrombosis was suspected.ConclusionsWe experienced a case of venous thrombosis that developed 20 years after diagnosis of GPA, although GPA is frequently associated with venous thrombosis immediately after diagnosis. The thrombosis progressed rapidly and was resistant to treatment.

S2395 A Series of Unfortunate Events: A Unique Case of Multiple Small Bowel Malignancies in the Setting of Inflammatory Bowel Disease

Introduction: Crohn’s disease (CD) is known to increase malignancy risk. Both large and small bowel adenocarcinoma and intestinal carcinoid tumors have been reported at increased rates in patients with CD but rarely concurrently. Additionally, there is an association between Non-Hodgkin Lymphoma and CD, however this is attributed to the use of immunosuppressive medications. We present a patient with a history of follicular lymphoma and ileal CD who later developed two separate small bowel malignancies. Case description/methods: The patient is a 63-year-old male with hypertension, chronic kidney disease, pulmonary embolism, and follicular lymphoma. His follicular lymphoma was diagnosed in 2009 by axillary lymph node biopsy after presenting with lower extremity swelling, night sweats, and weight loss. Staging CT scans prior to treatment demonstrated thickening of the ileum. He was treated with chemotherapy for two years and then remained on maintenance therapy. Five years after diagnosis, the patient was evaluated for 20 years of intermittent diarrhea. Endoscopic evaluation revealed CD of his ileum as well as a duodenal nodule. Elevated serum gastrin and chromogranin A levels, a positive octreotide scan, and EUS fine needle aspiration confirmed the nodule as a stage 1 duodenal carcinoid tumor which was subsequently resected. The following year, he developed fatigue and was noted to have iron deficiency anemia. Repeat EGD and colonoscopy was unrevealing thus he had a video capsule study which demonstrated narrowing of his ileum. CT enteroclysis revealed inflammation in his ileum. He underwent a small bowel resection and surgical pathology confirmed intestinal-type moderately differentiated adenocarcinoma of the ileum. Discussion: This case describes a unique course of a patient with follicular lymphoma and CD developing two small bowel malignancies related to underlying CD. While there are reports of CD developing as a treatment related complication of NHL and NHL developing as a treatment related complication of CD, our patient likely had untreated CD at time of his lymphoma diagnosis. This untreated CD likely led to the development of adenocarcinoma and his carcinoid is also likely associated with his CD. While it is rare to develop multiple small bowel malignancies, this case highlights the importance of maintaining a high index of suspicion of symptom changes in CD patients as they may be indicative of treatment specific and/or CD complications which may ultimately change management.

NOTHING TO HIDE UP YOUR SLEEVE: A RARE PRESENTATION OF DISSEMINATED NOCARDIOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Nocardia is a unique member of the order, Actinomycetales. It is a gram-positive, aerobic bacteria that is characterized by its filamentous branching that stains acid-fast. It can be found in soil and decaying vegetation, with inhalation of airborne particles being the most common mode of inoculation. Considered to be a rare, opportunistic infection, the incidence rate is approximately 500-1000 cases in the US per year (1). Although it typically leads to cutaneous disease, Nocardia has the ability to disseminate as widespread disease leading to pulmonary and CNS involvement. CASE PRESENTATION: An 81 year old African-American female with a past medical history of non-Hodgkin Lymphoma treated with radiation in 1999, hypertension, diabetes, hypothyroidism, chronic kidney disease, and heart failure with preserved ejection fraction. She presented with worsening dyspnea, orthopnea, and lower extremity swelling and was admitted for heart failure exacerbation. She was found to have multiple, painful skin abscesses. On presentation, she was septic: febrile and tachycardic with profound leukocytosis. Radiographic imaging revealed multiple, large, cystic fluid collections in the neck, bilateral arms, and left leg along with right, hilar lymphadenopathy and apical cavitary lesion in the right lung. There was a large, anterior chest wall mass communicating with the left arm lesion. IR guided biopsy ruled-out malignancy. General surgery performed I&D's of the peripheral lesions whereas Cardiothoracic Surgery performed I&D of the chest wall mass. Aerobic cultures grew gram-positive, branching bacilli that later speciated to Nocardia pneumoniae. DISCUSSION: The patient was diagnosed with Disseminated Nocardiosis with lymphocutaneous and pulmonary involvement. Our work-up was negative for CNS or bone disease. The exact etiology was unclear. She did not endorse direct trauma/inoculation at lesion sites and denied any unusual exposure to soil, decaying vegetation, or aquatic environments. Despite Nocardia's prevalence in immunocompromised hosts, our patient was determined to be immunocompetent. Fortunately, there was no evidence of recurrence of malignancy and she was HIV negative. Her treatment regimen consisted of a dual agent induction therapy for 6 weeks that was followed by a 6 month maintenance period with a single agent. However, Nocardia has a propensity to recur or progress despite appropriate antibiotic therapy and source control. CONCLUSIONS: Nocardiosis has been described as an emerging infectious disease given the higher number of HIV and transplant patients. Notably, Nocardia pneumoniae is not accounted for in 82 percent of US strains isolated between 1995 and 2004 (2). This species was first described in 2004 with either "undetermined clinical significance" versus "pulmonary disease" (3). This would be a novel presentation of disseminated Nocardia pneumoniae in an immunocompetent host. REFERENCE #1: Rawat D, Rajasurya V, Chakraborty RK, et al. Nocardiosis. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526075/ REFERENCE #2: Uhde KB, Pathak S, McCullum I Jr, et al. Antimicrobial-resistant nocardia isolates, United States, 1995-2004. Clin Infect Dis 2010; 51:1445. REFERENCE #3: The Complexities of Nocardia Taxonomy and IdentificationPatricia S. Conville, Barbara A. Brown-Elliott, Terry Smith, Adrian M. ZelaznyJournal of Clinical Microbiology Dec 2017, 56 (1) e01419-17; DOI: 10.1128/JCM.01419-17 DISCLOSURES: No relevant relationships by HUY NONG, source=Web Response No relevant relationships by Michael Vu, source=Web Response