Louisiana Research Day Program Book 2025

Case Studies: Section 2

Case Studies: Section 2

Hamama Javaid, MD; Niku Thapa, MD; Navin Ramlal, MD; Nauman Khalid, MD Department of Medicine, St. Francis Medical Centre, Monroe, LA 105 UNIQUE PRESENTATION OF COR TRIATRIATUM SINISTER IN AN ELDERLY PATIENT WITH ATRIAL FIBRILLATION AND MITRAL VALVE REGURGITATION

Dirgha Patel MD, Hamama Javaid MD, Navin Ramlal MD, Imran Ali Khan MD Department of Medicine, St. Francis Medical Centre, Monroe, LA. 106 RARE PRESENTATION OF SPLENIC ACTINOMYCOSIS IN AN IMMUNOCOMPETENT HOST, A LONG-TERM SEQUELAE OF BOWEL PERFORATION

Case Description: A 69-year-old male with known history of hypertension, non-ischemic cardiomyopathy and paroxysmal atrial fibrillation presented to the ED with chest tightness of several hours. He also reported orthopnea, dyspnea on exertion, oliguria and bilateral lower extremity swelling alongside of a weight gain of 5-6 pounds over the preceding days. His initial vital signs were stable except for a mild fever of 100°F. Physical examination revealed bibasilar rales on lung auscultation and pitting edema in both lower extremities. Initial labs revealed an elevated BNP of 7663 (N < 100) and a mild elevation in troponins at 0.07 (N < 0.05) with an EKG showing his known right bundle branch block. Subsequent chest X-ray showed evidence of pulmonary edema, which alongside of his previously known left ventricular ejection fraction of 35-40% and current clinical symptoms, confirmed a diagnosis of acute on chronic congestive heart failure. Patient was initiated on diuretic therapy with bumetanide. Due to an insufficient response to treatment, decision was made to proceed with a right heart catheterization by cardiology which showed an elevated PA pressure consistent with pulmonary hypertension likely due to volume overload.

He was subsequently started on furosemide and dobutamine infusions, however developed atrial fibrillation with rapid ventricular response (RVR) post-catheterization prompting the discontinuation of dobutamine and initiation of amiodarone. Due to persistent RVR despite treatment, he underwent a transesophageal echocardiogram for cardioversion. During this procedure, a fenestrated membrane in the left atrium (cor triatriatum sinister) and severe mitral regurgitation were discovered. Cardiothoracic surgery was consulted for mitral valve repair, who recommended medical optimization prior to the procedure. He was stabilized and discharged to home on guideline-directed medical therapy. Subsequent outpatient evaluations, including repeat right and left heart catheterization, revealed no significant abnormalities and after discussion regarding his cardiac structural anomalies, decision was made to proceed with Mitra Clip placement for mitral valve repair. No intervention was deemed necessary for the cor triatriatum sinister. Discussion: Cor triatriatum sinister (CTS) is a rare congenital heart defect primarily seen in children, often resulting in pulmonary congestion

due to increased left atrial pressure. While adults with CTS typically remain asymptomatic due to foraminal openings between the atrial chambers, they can become symptomatic over time and develop exertional dyspnea, atrial arrhythmias or embolic events. The management of CTS focuses on symptomatic treatment. Surgical intervention is rarely necessary in adults and is considered on a case-by-case basis, emphasizing the need for personalized management strategies in similar clinical scenarios.

Case Description: A 46-year-old male with recent admission to our hospital several months prior for a bowel perforation secondary to acute diverticulitis presented to the emergency department with a one-week history of left sided upper abdominal pain with associated high-grade fever, nausea, poor appetite and a non-productive cough. In addition to this, since his last admission during which he had underwent exploratory laparotomy with partial colectomy and drainage of a peritoneal abscess, he also reported an unintentional 30-pound weight loss. Initial vital signs revealed a low grade fever and borderline low blood pressures. On physical examination, he had significant tenderness on palpation of his left upper quadrant. Initial labs showed a leukocytosis of 16.4 (N 4.0-10.0). Initial imaging with contrasted CT chest, abdomen and pelvis showed evidence of interval development of large liver and splenic lesions, that had not been present his previous admission. In addition to this, he also was found to have multiple pulmonary nodules throughout his bilateral lungs. Empiric treatment with broad spectrum antibiotics was initiated on the suspicion of a disseminated infection but patient remained febrile with

worsening of his leukocytosis. Infectious disease consultation was then requested, after which his antibiotic treatment was escalated to high dose piperacillin-tazobactam and vancomycin. ID also recommended IR-guided drainage of the splenic abscess, the culture of which ultimately resulted positive for Actinomyces Israeli in addition to other Bacteroides and Prevotella species. Based on his culture results, antibiotics were readjusted to a 6-week course of high-dose IV penicillin G and oral metronidazole, with plans to initiate a prolonged course of oral amoxicillin thereafter until radiologic resolution of the disseminated actinomyces lesions was achieved. Patient’s clinical condition improved gradually during the hospitalization. Repeat CT chest, abdomen and pelvis after 6 weeks of IV antibiotics course showed marked improvement of hepatosplenic and pulmonary lesions. Discussion: Actinomyces species are part of normal mouth, gut and genital tract flora and are almost always seen in mixed infections, usually involving other anaerobic species. The main risk factors for disseminated actinomycosis occur in the setting of trauma, bowel perforation and/or complications from

surgical procedures. Oro-cervical presentations are most common, with abdomino-pelvic involvement being less common and splenic involvement rarely being seen, especially in immunocompetent hosts. This case highlights the importance of considering atypical infections like actinomycosis in the differential, especially in patients with a history of bowel perforation. Treatment is challenging, and morbidity and mortality can be high if actinomycosis is not recognized and treated in a timely manner.

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