OHSU Internal Medicine Residents’
Clinical and Research Abstract Presentations
American College of Physicians
Oregon Chapter Scientific Meeting
November 7, 2013
Salem, OR


Oral Presentations

Research Posters

Clinical Vignette Posters


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“A Hemolytic Quandary”—WINNER, 1st Place
Nathanael Gay, MD

G6DP deficiency is a known cause of acute oxidative hemolysis.  In this case this seemed to be triggered by fava bean ingestion inducing oxidative stress that patients system could not compensate for. The differential in this case was broad and included toxin/infection mediated hemolysis, hereditary spherocytosis along with pyruvate kinase and hexokinase deficiencies. G6PD deficiency is an x-linked recessive condition and it is atypical for females to become symptomatic however her fava bean consumption could given her enough oxidative stress her into hemolysis even in the setting of her mild to moderate G6PD deficiency.  In the acute phase reaction her initial G6PD screen was negative which is known to be the case acutely and only after repeat reference lab G6PD testing was her deficiency and the diagnosis of favism revealed.



The Deadliest Cancer “Cure”
Michael Hendricks, MD

No longer marginalized to the realm of medical sideshow, among the historical likes of phrenology and snake oils, alternative therapies now represent a viable adjunct to conventional medicine.   New diagnostic challenges spawn from this rise in popularity, however, as many of these nostrums are manufactured and sold with minimal Food and Drug Administration (FDA) safety oversight.   We present a case of near fatal toxicity in a patient taking a homeopathic remedy marketed online as a benign, and universally effective, cancer treatment.






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Extramedullary Multiple Myeloma Associated with Reduced Overall Survival: A Retrospective Single-Center Study
Ido Barkay, MD; Richard T. Maziarz, MD; Andy Chen, MD, PhD; William Dibb; Yiyi Chen, PhD; Emma Scott, MD

Multiple Myeloma (MM) is an incurable neoplasm, however recent advancements in therapies have led to median overall survival of 7-10 years in standard risk patients. High risk patients still succumb to the disease within 3 to 5 years. Traditionally used clinical prognostic markers such as the International Staging System (ISS), the Durie-Salmon (DS) staging system, and cytogenetics do not adequately predict response to novel agents or overall prognosis. We previously presented data identifying high risk sub-groups that succumb to shorter progression free survival (PFS) and overall survival (OS) after hematopoietic stem cell transplant (HSCT). Extramedullary disease (EMD) was a highly significant risk factor for poor survival.



Cost Conscious Utilization of Diagnostic Tests—WINNER, 1st Place Quality Improvement
Lawrence Huan, MD; Michael Hendricks, MD; Erin Fender, MD; Alan Hunter, MD; Sima Desai, MD; Sudhakar Karlapudi, MBBS

In 2011, national health care expenditure was $2.7 trillion, up from $253 billion in 1980 and accounted for 17% of the Gross Domestic Product. It is estimated that one third of these costs are wasted on unnecessary tests, approximately $810 billion dollars per year.  Efforts to stem this unsustainable growth have focused on educating practioners about cost-conscious care, particularly residents. Thus, we implemented an educational intervention and studied its impact on the utilization of laboratory tests and phlebotomy in an academic institution.



Defining Cultural Competence
Qian Leng, MD, MPH; Somnah Saha, MD; Martha Gerrity, MD

In the past 2 decades, there has been increasing awareness of the diversity of the US population and the demands of providing care to such a wide group. This has led to interest in cultural competence. Many health care professionals view cultural competence as the ability to work effectively with a wide group of patients, including those from an ethnicity different than that of the provider. New medical school and undergraduate courses have been designed to teach cultural competence. However, there still lacks a cohesive definition cultural competence. In order to answer this question, a review of the literature is being conducted.





QTc Monitoring in Patients on Methadone at a Federally Qualified Health Center—2nd Place Quality Improvement
Lidija McGrath MD; Meg Devoe MD.

Methadone is an opioid agonist used in the treatment of opioid addiction and chronic pain, with an FDA-issued black box warning cautioning the risk of serious arrhythmias due to QTc prolongation. Ventricular arrhythmia and cardiac arrest are the most frequent methadone attributed adverse events reported to the FDA.  Two separate guidelines recommend that patients prescribed methadone undergo annual ECG screening. The aim of this study was to examine the adherence to screening recommendations in patients on methadone at a federally qualified health center (FQHC) in Portland, Oregon.



Indications for Colonoscopy Leading to the Detection of Advanced Neoplasia in Patients 40 to 49 Years Old—2nd Place Clinical Research
Karen Saks, MD; Jennifer L. Holub, MPH; David A. Lieberman, MD

The presenting signs and symptoms prompting physicians to order a colonoscopy for patients under age 50 years old are unclear. Our study evaluates signs and symptoms in patients age 40 to 49 years old to identify clinical predictors of advanced neoplasia at colonoscopy.





Rifaximin is Associated with Decreased Rates of Spontaneous Bacterial Peritonitis in Patients with Cirrhosis—1st Place Clinical Research
Susanne Shokoohi, MD; Adam Zivony, MD; T. Domi Le, MD; Atif Zaman, MD, MPH; Janice Jou, MD, MHS

Rifaximin is a non-absorbable antibiotic used for the treatment of hepatic encephalopathy (HE). Given its limited systemic absorption and antibacterial spectrum, rifaximin is an intriguing candidate medication for spontaneous bacterial peritonitis (SBP) prophylaxis as well. The potential effect of rifaximin on the incidence of SBP in patients with cirrhosis and ascites is unclear. The aim of this study was to assess the association of rifaximin with SBP in cirrhotic patients.






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The Masquerader: Pulmonary Actinomycosis, a Rare Etiology of Empyema in Developed Countries
Reyhaneh Akhavein, MD; Kyle Kent, MD

Thoracopulmonary Actinomycosis is rare and commonly misdiagnosed as it mimics a wide variety of lung pathologies particularly bronchogenic carcinoma, pleural effusion, tuberculosis, and pneumonia.  It constitutes 15–20% of Actinomycosis cases and is highly treatable when detected early.






A Rare Etiology of Back Pain: Solitary Plasmacytoma of Bone Resulting in Pathologic Vertebral Fracture
Reyhaneh Akhavein, MD

A 73 year-old man with history of monoclonal gammapathy of undetermined significance that had remained stable for the past 9 years presented with progressive back pain over the course of few months in the absence of neurologic symptoms or trauma.






When is a Tumor…Not?  A Treatable Diagnosis Not to Be Missed.
Ashvin Baru, MD; Ryan Clay, MD; Dean Peterson, BA; Alan Hunter, MD

A cecal mass with terminal ileitis has a broad differential of both neoplastic and non-neoplastic etiologies. We present a case of a large Yersinia enterocolitica cecal abscess mimicking a tumor, complicated by bacteremia in a transplant recipient.






Relapsing Polychondritis Mimicking Orbital Cellulitis
Katie Camilleri, MD; Kacy Church, MD; Jake Lenington, MD; Devan Kansagara, MD

Relapsing Polychondritis is a rare autoimmune condition characterized by episodic, progressive inflammatory destruction of cartilaginous structures, including the eye, which can mimic orbital cellulitis.  This case presented the question of using high dose steroids in a patient with orbital cellulitis that was not responsive to antibiotics.





SMV Thrombosis in a Patient with Chronic C. difficile Infection
Elizabeth Cathcart-Rake, MD; Qian Leng, MD, MPH

The case of Mr. JS posed both diagnostic and treatment dilemmas. His initial complaint of abdominal pain could be explained by the SMV thrombosis, or several other causes: alcoholic gastritis, C. difficile infection, or GERD. There have been case reports of C. diff causing pylephlebitis as well as abdominal trauma precipitating SMV thrombosis. While it remains unclear how much his abdominal pain was due to the thrombus, it appears certain that the thrombus resulted from a perfect confluence of prothrombotic conditions: abdominal infection, chronic inflammation, hypercoagulability, and recent abdominal trauma.



Warfarin-related Nephropathy: When CKD and Anticoagulation Collide
Erin Chamberlain, MD; Sima Desai, MD

CKD predisposes patients to thromboembolic disease secondary to loss of anticoagulant proteins and changes to procoagulant proteins. However, overanticoagulation and major hemorrhage occur at twice the rate in patients with CKD on warfarin therapy. Warfarin-related nephropathy (WRN) is a newly described entity of acute kidney injury caused by glomerular hemorrhage and tubular obstruction caused by RBC casts.






Progressive Neurologic Decline Provides Strokes of Insight
Cherry Chen, MD; Renee Dversdal, MD

In AIDS patients, PML occurs due to reactivation of JC virus in the setting of decreased CD4+ T cells, which play a crucial role in cellular immune response.  Symptoms are usually subacute with progressive neurologic deficits that can be mistaken for stroke.






Aspirin: Friend or Masked Killer? A Rare Case of a Penetrating Gastroduodenal Ulcer
Carlene Chun MD, PhD; Ryan Childers, MD; Brian Fennerty, MD

Peptic ulcer disease (PUD) is the most common cause of upper gastrointestinal bleed (UGIB) in hospitalized patients in the United States. The majority of UGIB are treated non-surgically and rarely do ulcers penetrate surrounding organs. Here we present a case of a severe UGIB caused by an giant iatrogenic ulcer that eroded into the pancreas, mesocolon and the pancreaticoduodenal artery.







Dapsone Hypersensitivity Syndrome as a Presentation of DRESS
Kacy A. Church, MD; Reyhaneh M. Akhavein, MD; Andre Mansoor, MD

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a drug-induced hypersensitivity that typically occurs two to six weeks after the initiation of an offending medication. It is a multi-systemic syndrome that causes a constellation of signs and symptoms that may include rash, lymphadenopathy, hematologic abnormalities of eosinophilia and atypical lymphocytosis, and inflammation of the lungs, liver, and kidneys.  Dapsone hypersensitivity syndrome, unlike DRESS caused by most other medications, also often elevates the methemoglobin level. Management of DRESS is primarily supportive with removal of the offending agent. In patients with severe organ involvement, particularly in those with pulmonary or renal involvement, the use of systemic corticosteroids is recommended. Most patients will have complete recovery weeks-months after removal of the offending drug.


Lines of Fire: Erythema Ab Igne, An Unusual Rash from a Common Therapy
Kacy Church, MD; Lauren Moffitt, MS; Rob Hinz, MD; Joseph Chiovaro, MD

Erythema ab igne is considered a type of a thermal burn injury akin to infrared radiation.  Similar to actinic keratosis, neutrophil-derived proteolytic enzymes may be responsible for the histopathologic changes which include squamous atypia in the epidermis. Removal of the inciting cause is the mainstay of therapy.  Following removal of the stimulus, the discoloration gradually lightens after several months to years, although long standing pigmentations have been reported.  If the rash is severe or becomes ulcerated, there is increased risk for squamous cell carcinoma and a biopsy may be indicated if the lesion does not heal.



Hyperactive Delirium
Kathleen Drago, MD; Elizabeth Eckstrom, MD

Delirium occurs in ~20% of inpatients and ~50% of terminally ill cancer patients, costing the healthcare system upwards of $30 million per year for management. The following case describes the successful management of severe hyperactive delirium in the absence of pharmacologic therapy.







Hiding in Plain Sight: Discovery of Chronic Hepatitis B in an Inflammatory Bowel Disease Patient in Need of Urgent anti-TNF Therapy
Jeffrey M. Dueker, MD, MPH; Stephanie Halvorson, MD

Patients with steroid-refractory inflammatory bowel disease (IBD) may require additional immunosuppression to induce remission, commonly with anti-tumor necrosis factor (anti-TNF) alpha agents. Anti-TNF agents are potent suppressors of host defenses and may increase the risk of serious infections and malignancies. There is general agreement among gastroenterologists that patients should be screened for hepatitis B (HBV) and other infections prior to initiation of therapy.




Persistent Kidney Injury in a Transplant Patient: A Case of Xanthrogranulomatous Pyelonephritis
Melissa Hayden, MD; Suzanne Watnick, MD

This is a description of kidney injury due to granulomatous infiltration of a transplanted kidney in a patient with chronic urinary tract infections on high dose immunosuppression.






Moans, Groans, Stones, and STEMI overtones
Lawrence Huan, MD; Peter Sullivan, MD

A 68 year old with a history of schizophrenia and nephrolithiasis with subsequent pyelonephritis requiring nephrectomy, presents to the emergency room for a witnessed syncopal event.  Serum calcium was 17.6 mmol/L with an ionized calcium 1.96 mmol/L.  Electrocardiogram showed 3mm ST-elevations in leads v3-v6, without active chest pain.  Literature review does indicate several case reports that suggest severe hypercalcemia has the ability to mimic ST-elevation myocardial infarction, which is the most probable etiology here. 



DRESS Associated Myocarditis: What Every Internist Needs to Know
Briana Jelenc, MD; Peter Sullivan, MD

Drug related eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal syndrome consisting of a cutaneous drug reaction and varying organ system involvement. Although the liver is the most frequently affected organ, DRESS-related myocarditis is a fairly common but under-recognized manifestation that can occur weeks to months after initial rash and can progress to acute necrotizing eosinophilic myocarditis (ANEM), which is fatal in >50% of patients. We present a case of DRESS-related myocarditis from exposure to vancomycin,





A Rare Case of Decompensated Heart Failure and Transient Ischemic Attack with a “Compact” Unifying Diagnosis
Brian Jeppesen, MD

Although LVNC is a rare clinical entity, the incidence is expected to rise with growing recognition given the increasing ubiquity and sensitivity of cardiovascular imaging. For general providers, LVNC is a consideration for patients presenting with new onset heart failure, dysrhythmia or thromboembolic disease.





Parvovirus B-19 Pure Red Cell Aplasia Complicating Concurrent Lupus-Associated Autoimmune Hemolytic Anemia.
Andrew Lawton, MD; Aaron Spaugy, MD; Alan J. Hunter, MD

This case illustrates how parvovirus infection with resultant aplastic crisis can cloud the clinical presentation of AIHA.  While reticulocytopenia in the setting of suspected AIHA may represent intramedullary destruction of reticulocyte precursors or nutritional deficiencies, clinicians should also consider marrow suppression and red cell aplasia due to a separate clinical entity, including parvovirus infection.




Breathing Easily at Eighty Five Percent: Sudden Oxygen Desaturation after Rasburicase Administration
Elizabeth C Lee, MD; Jennifer LeTourneau, DO

Purine metabolism poses a unique challenge to humans among mammals due to relatively high levels of serum uric acid which is directly secreted into the urine. When elevated, uric acid can precipitate in the renal tubules leading to vasoconstriction and acute kidney injury. Rasburicase is a recombinant urate-oxidase enzyme approved for use in hyperuricemia associated with malignancy. This case focuses on the use of rasburicase in a man with hypercalcemia and hyperuricemia of malignancy and resultant methemoglobinemia.




Adult Onset Autoimmune Enteropathy
Sarah Lee, MD; Zibing Woodward, MD; Ellen Flatley, MD; M. Brian Fennerty, MD

Autoimmune enteropathy is a rare disorder that presents predominantly in children with intractable diarrhea unresponsive to diet modification.






Peritoneal Mesothelioma in a Young Woman
Qian Leng, MD, MPH

The case of Ms. JR is extremely unusual in that she was a young woman, had peritoneal mesothelioma instead of pleural disease, and had no known asbestos exposure. The incidence of mesothelioma in the United States is about 1.5 per 1,000,000 person-years. The rate among women is half of that among men. Furthermore, three quarters of all cases originate from the pleura with only rare cases involving the  peritoneum. The majority of mesothelioma cases are associated with occupational asbestos exposure and tend to develop 20-30 years later.





Anti-N-methyl-d-aspartate Receptor Encephalitis: an Under-recognized Cause of Altered Mental Status
Katherine Mackey, MD; Marissa Maier, MD; Kimberly Hutchison, MD

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis results from an immune response against extracellular epitopes of the NR1 subunit of the NMDA receptor. The disorder was first described in 2007 and is becoming recognized as an important cause of encephalitis.





Break-Bone Fever
Stephanie Mittelstaedt, MD, MPH; Kyle Kent, MD

Dengue fever is an important illness facing travelers to endemic areas now encompassing over 100 countries, many of which have a high prevalence of infection.  Certain clinical features may be more suggestive of infection with dengue virus as compared with other etiologies in a patient presenting with fever and exanthema.  Awareness of these features may help the clinician to avoid pitfalls in laboratory interpretation.




Serositis – A Not So Unusual Presentation of Late-Onset Systemic Lupus Erythematosus
Emily Ames Morgan, MD; Joseph C. Chiovaro, MD

While the overall prevalence of lupus decreases with age, approximately 10-20% of cases occur in older patients.  Elderly-onset SLE often presents with non-specific symptoms that differ from symptoms classically seen in younger-onset lupus. Serositis, arthritis and fever are common presenting complaints in this group, while skin manifestations and renal failure are less common.  Most patients have a positive ANA titer regardless of age at diagnosis, but elderly patients have a lower prevalence of anti-Smith autoantibody, anti-ribonucleoprotein antibody, and hypocomplementemia.  Limited evidence exists to guide treatment for patients with elderly-onset SLE.  While treatment of SLE in the elderly is similar to treatment in younger patients, elderly patients often have more comorbidities and may have increased risk of toxicity with usual treatment.  Not unexpectedly, there is increased mortality in patients with elderly-onset SLE, which is usually caused by cardiovascular disease or malignancies.  Understanding these key features of elderly-onset lupus could potentially lead to earlier diagnosis and treatment for these patients.

A Diagnosis of Malignancy from Simple Urinalysis
Srini V. Mukundan, MD; Sharon Anderson, MD; Kirstin Woolf, MD

Diffuse Large B-cell Lymphoma (DLBCL) usually presents as an aggressively growing mass, typically diagnosed by lymph node biopsy.  In this unusual case, we describe the diagnosis of DLBCL made from simple urinalysis.







Shiga Toxin-producing Escherichea Coli Hemolytic Uremic Syndrome (STEC HUS) Evolving to Atypical HUS
Go Nishikawa, MD; James Bordley, MD; Thomas Deloughery, MD, PhD

Atypical hemolytic syndrome is a newly recognized entity with a similar clinical presentation to STEC induced HUS. They both present with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Atypical HUS is differentiated by the absence of shiga toxin and has a different pathopyhsiology involving decreased regulation of alternative complement pathway.





The Wrong Arthritis—WINNER, 1st Place Clinical Vignettes
Andrew Oehler, MD; Ellen Flatley, MD; James Bordley, MD

Inflammatory arthritis carries with it a broad differential diagnosis perplexing to the general internist, even more so in the face of a daunting serologic analysis with therapeutic and prognostic implications. 





Secondary Raynaud’s Phenomenon
Amirala Pasha, DO

This illustrates a case of secondary Raynaud’s phenomenon, risk factors associated with secondary causes and the importance of thorough and complete workup and follow up for diagnosis of underlying disease.






A Case of Suspected Paraneoplastic Pemphigus
Veena Patel, DO; Akram Khan, MD

Paraneoplastic pemphigus (PNP) is a rare autoimmune disease characterized by painful mucocutaenous lesions most commonly associated with lymphoproliferative disorders, carcinomas and thymomas (6 % of patients). Diagnosis is made with a combination of clinical features, laboratory and histopathological findings. PNP can predate the recognition of malignancy in approximately one third of patients and our case illustrates the importance of evaluation for malignancy in an elderly patient presenting with new onset pemphigus. Muco-cuntaenous lesions of PNP can lead to complications that have high morbidity and mortality such as dehydration, infection and airway compromise with respiratory failure therefore these patients should be monitored closely.  In cases of PNP associated with thymoma resection can often result in resolution of muco-cutaneous lesions.


What can PET do for you? – Use in Fever of Unknown Origin—2nd Place Clinical Vignettes
Sriram Ravi, MD; Kerry Rhyne, MD

Fever of Unknown Origin (FUO), first defined in 1961 by Petersdorf and Beeson, continues to be a formidable challenge, and requires a very extensive differential diagnosis. Over the years, laboratory and technological advances have helped identify many pathologic causes. However, despite these advancements, roughly 20-30% of FUO remain undiagnosed. As a result, newer diagnostic modalities are being incorporated in solving these diagnostic dilemmas.




A Hematologic Trifecta in a Sickle Cell Patient
Matthew H. Richards, MD; Lynn Boshkov, MD

Though sickle cell disease is not an uncommon disease, it is underrepresented in Oregon.  As we are not exposed to this disease as frequently it is important to be aware of the potentially lethal as well as the common manifestations.  Acute chest syndrome is a severe complication of sickle cell disease at its variants with a 3% mortality rate. Additionally common manifestations and complications including vaso-occlusive phenomenon, infections, and transfusion related complications are common entities to be able to manage. 




Lumps and Bumps, Could it be Cancer?
Matthew H. Richards, MD; Renee Dversdal, MD

Syphilis is a disease described in the medical literature for centuries with a variety of presentations and complications.  Even since the arrival of penicillin, the rates of syphilis continue to rise.  Recently, the rates in Oregon, especially Portland, have had a dramatic increase.  Due to is multiple forms and varied presentation, it becomes an important component of the differential diagnosis for a number of symptoms.





Weakness in a Myasthenic Patient: Avoiding Early Closure and Anchoring
Hannah Rose, MD; Joseph Hardman, MD

This patient's first words to the admitting team were "Docs I'm tired. I have myasthenia and need plasmapharesis." A thorough physical exam helped the team avoid diagnostic pitfalls, ultimately distinguishing between a myasthenic crisis and a more grave etiology.






SIRS and Acute Painful Nodular Rash in a Patient with Leprosy
Sarah Soltman, MD; James Clements, MD

Erythema Nodosum Leprosum (ENL) is an immune-mediated complication of Leprosy that presents with inflammatory skin nodules and systemic symptoms. It is important to diagnose early since effective treatment exists, without which the associated inflammation can lead to nerve injury causing permanent deformity.





Abrupt Osmotic Shifts followed by Unexplained Neurologic Phenomena:  A Case of Reversible Cerebral Vasoconstriction Syndrome
Aaron Spaugy, DO; Andrew Lawton, MD; Alan J. Hunter, MD

This case highlights a rare, but increasingly recognized cerebrovascular syndrome which providers should consider when evaluating patients with neurologic findings either following severe thunderclap headaches, or whose occurrence and/or evolution cannot be explained.  While there is no definitive therapy, early diagnosis will allow withholding of potentially risky therapeutic anticoagulants, and cessation of known vasoactive triggers.





Chronic Norovirus in an Immunocompromised Host
Brad Stauber, MD

While norovirus generally presents as a self-limited winter-time diarrheal illness, challenges arise in the workup and differential of persistent diarrhea in a patient without a functioning immune system.  Persistent norovirus burden is a difficult to treat infection not uncommon to the immunocompromised patient population.





Lithium Related EKG Changes Despite Dialysis
Leah M. Wilson, MD; Melissa Weimer, DO, MCR

Lithium has historical medicinal use dating back to the 1800s. It has been FDA approved for use in mania since 1970. In 2011, 6,737 reports of lithium toxicity were reported to the American Association of Poison Control Centers’ National Poison Data System.





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