Auburn Research Day 2021

Mary Klacik, OMS-III; Alison Nguyen, OMS-III; Elaina Furr, OMS-IV; Richard Stewart Hargrove, DO; Syed Zaidi, MD; Kashyap Patel, MD LewsGale Medical Center, Salem, VA Cl i n i ca l Case Repor t | Med i ca l St udent Diverticulitis Vs. Acute Alpha Gal: Is it Seeds, Nuts, or Cows that are Playing Havoc on your Bowels? 020

Alpha Gal syndrome is a recently discovered food allergy to red meat and other mammalian products. It was first described in 2009 as a delayed IgE anaphylaxis response to the carbohydrate, Galactose alpha-1,3-Galactose (Alpha Gal). In the United States, Alpha Gal Syndrome most commonly begins with a Lone Star tick bite that transfers the sugar molecule, alpha gal, into a human’s body. The immune system responds by forming IgE antibodies to the alpha gal antigen. This causes mild to severe allergic reactions to red meat and other mammalian products. Because Alpha Gal Syndrome is associated with oral intake, it can be presumed that it would commonly present with gastrointestinal (GI) symptoms. Interestingly, there have not been many cases of Alpha Gal presenting with GI symptoms. This is a unique case of Alpha Gal Syndrome that is commonly misdiagnosed as other GI disorders. A 61-year-old female experienced crampy abdominal pain, vomiting, abdominal distention, profuse diarrhea, and fever (103.2°F) after eating a packaged salad, frozen turkey burger and broccoli. She was previously diagnosed with Alpha Gal Syndrome and has abdominal cramping, nausea, and vomiting after eating red meats. She recently

eliminated red meat from her diet and her abdominal symptoms had gone away until she presented to the hospital. On physical exam she had diffuse abdominal tenderness to palpation. She was admitted to the hospital and the abdominal CT scan showed acute diverticulitis of the descending colon. Stool lactoferrin and Fecal Occult Blood Test were positive. WBC was 10.34 with a left shift of 30% bands. She was managed on Ceftriaxone, Metronidazole, and IV fluids. After two days of treatment she reported decreased abdominal pain, the diarrhea had ceased, and she was afebrile. She was discharged home and advised to continue to avoid triggers of her Alpha Gal Syndrome. The patient’s presentation of diverticulitis can be explained by a possible IgE response in the colon causing an episode of inflammation. In 3-20% of cases, patients report isolated gastrointestinal symptoms in the absence of anaphylaxis (Commins, 2020). However, further research is needed to explain the pathophysiology of an IgE reaction in the large intestine. The unawareness of this disease presenting as isolated gastrointestinal symptoms result in many patients being misdiagnosed with Irritable Bowel Syndrome or other GI conditions.

Cl i n i ca l Case Repor t | Med i ca l St udent Association of an Interatrial Septal Aneurysm and Paradoxical Emboli

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Mary Klacik, OMS-III; Alison Nguyen, OMS-III; Austin Rallis, MD, PhD; Bao Nguyen, MD; Kashyap Patel, MD LewisGale Medical Center - Salem, VA

An Atrial Septal Aneurysm (ASA) is a localized saccular deformity of the atrial septum that protrudes into right or left atrium at least 10-15 mm. This benign, rare condition can become a significant event when causing cerebral ischemia. It is unknown whether an intra-atrial embolism or a paradoxical embolism is the more common cause of a TIA in patients with an ASA. This case is unique in that it explains a possible mechanism of ASA’s association with recurrent TIAs. A 62-year-old female arrived to the emergency department as a transfer. She had abrupt onset of right arm weakness, right hand numbness and speech changes. She has a past medical history of TIA one month ago, interatrial septal aneurysm, HTN, HLD and breast cancer treated with chemotherapy and radiation. The patient was previously managed on Aspirin 81 mg daily, Pravastatin and Clopidogrel. During her hospital stay, she had an MRI that showed increased FLAIR on the left posterior temporal/ parietal gyri. TTE confirmed her interatrial septal aneurysm. Doppler Ultrasound of her bilateral lower extremities showed acute DVT involving the right popliteal, peroneal, gastrocnemius and soleal veins, also the left posterior tibial and peroneal veins. In addition to her current medications, she was given Heparin. After three days, her symptoms resolved, and she was discharged on Apixaban. In a study of 100 patients with cryptogenic TIAs, it was determined that patients with

an isolated atrial septal aneurysm >10 mm were eight times more likely to have a cryptogenic stroke (Cabanes, 1993). None of the patients in the study had evidence of intra-atrial thrombi, suggesting that paradoxical emboli caused the TIA. It was previously thought that paradoxical emboli were a minor cause of ischemic strokes, but it is now suggested that they can account for as many as 47,000 unexplained ischemic strokes in young patients each year (Travis, 2001). This patient’s atrial septal aneurysm predisposed her to paradoxical emboli resulting in recurrent TIAs. The emboli that caused her TIA likely originated from a thrombus in her lower extremity, which traveled through a PFO from her right to left heart and dislodged in her brain causing a TIA. This patient’s case can inform others about the association of an atrial septal aneurysm and paradoxical stroke originating from a DVT.

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