Louisiana Research Day Program Book 2025

Case Studies: Section 2

Case Studies: Section 2

Hamama Javaid; Sham Kumar; Usman Haq; Trisandhya Sharma; Mahesh Thapa; Imran Ali Khan Department of Graduate Medical Education, St. Francis Medical Center, Monroe, Louisiana. 107 MELIOIDOSIS PRESENTING AS URINARY TRACT INFECTION: A RARE PRESENTATION IN A NON-ENDEMIC REGION EMPHASIZING THE ROLE OF TRAVEL HISTORY.

108 A RARE CASE OF PENILE METASTASIS IN THE SETTING OF RENAL CELL CARCINOMA

Jeremy L. Rawson, MD; Nisheem N. Pokharel, MD; Pamraj Sharma St. Francis Medical Center Internal Medicine Residency Program; Department of Internal Medicine

Background: A 71-year-old male with a significant medical history, including Type 2 Diabetes (DM 2) and Hypertension, presented with complaints of polyuria, polydipsia, and an abrupt onset of urinary retention. Upon arrival, the patient exhibited normotensive but tachycardia, along with a fever of 101°F. Notably, the patient experienced marked bladder distension, resulting in lower abdominal pain. After urinary catheterization, the patient voided 1800 ml of urine. Laboratory results revealed elevated blood glucose (575 mg/ dL), an anion gap of 17, and lactic acid at 2.0, indicating Diabetic Ketoacidosis (DKA). There was suspicion that an underlying Urinary Tract Infection (UTI) triggered the DKA due to the presence of leukocyte esterase, nitrites, and bacteria in the urine analysis. A CT scan of the abdomen and pelvis disclosed bladder wall thickening and perivascular fat stranding, suggestive of cystitis. Consequently, the patient was admitted to the Intensive Care Unit (ICU) for DKA management. Before commencing empirical antibiotic treatment, both urine and blood cultures were obtained. The results from these cultures confirmed the presence of Burkholderia pseudomallei, indicating a

melioidosis infection. Consequently, antibiotic therapy was adjusted, incorporating meropenem and Bactrim for an extended treatment regimen. Despite showing improvements in DKA and laboratory values, the patient continued to experience fever. A subsequent CT scan revealed multiple lung nodules and patchy nodular opacities in the bilateral lower lobes, in addition to a small cavitary focus in the left upper lobe. Collaborative discussions with infectious disease specialists and epidemiologists prompted an extension of the initial intensive phase of IV antibiotic therapy. The patient’s leukocytosis resolved, liver functions improved, and the fever subsided. Over time, blood cultures eventually yielded negative results. Given the patient’s decision to return to his home country, Laos, after just two weeks of IV antibiotics, a treatment plan was established, consisting of an additional two weeks of IV meropenem, followed by six months of oral Bactrim DS BID. Discussion: The presentation of UTI in melioidosis is an unusual but clinically significant combination, often overlooked, contributing to diagnostic complexity. What sets this case apart

is the uncommon presentation of melioidosis as a UTI. It is noteworthy that the patient’s travel history from an endemic country like Laos played a pivotal role in early diagnosis, emphasizing the importance of considering travel history even in non-endemic regions. This case underscores the significance of swift identification and treatment, providing valuable insights for managing similar cases, particularly in regions where melioidosis is not endemic, while emphasizing the role of travel history in early diagnosis.

Introduction: Metastatic disease to the penis is an extremely rare entity with less than 500 cases reported in the literature, most commonly arising from solid tumors involving the bladder and the prostate. Less commonly, renal cell carcinoma (RCC) can also be associated penile metastases, accounting for approximately 10% of all described cases. Renal cell sarcomatoid differentiation, which is a subtype of RCC, is associated with higher stage at initial diagnosis and an overall poorer prognosis. Penile neoplasms present a significant diagnostic challenge and earlier diagnosis can lead to improved patient outcomes. Case Summary: A 73-year-old, non-smoking Caucasian male presented to the emergency department for evaluation 3 weeks following a penile injury, with worsening pain, swelling and urinary hesitancy. Physical examination revealed an uncircumcised phallus with associated glans tenderness and edema. He also had phimosis without scrotal edema. Initial labs were unrevealing, however further work up with CT abdomen/pelvis revealed evidence for marked penile soft tissue swelling, with a concerning 15.5 cm centrally necrotic heterogeneous mass

in the midportion of the right kidney. He was also noted to have a 2.1 cm right hepatic lobe cyst and a lobulated lucent S2 vertebral body lesion. CT chest showed multiple small nodules in his lungs. Ureteroscopy and biopsy of the glans penis was completed, the final pathology of which revealed non-small cell carcinoma consistent with metastatic papillary renal cell carcinoma. A subcostal open right radical nephrectomy was subsequently performed, revealing an 18x13 cm papillary renal cell carcinoma type 2, with sarcomatoid features. Patient was diagnosed with grade 4 malignancy. Negative pathology margins and lymph nodes corresponded to a final T3NxM1, indicating stage IV. Palliative systemic chemotherapy was offered to him, but he declined. Patient subsequently underwent 10 cycles of radiation therapy for ongoing penile pain. Given concerns of severe and poorly controlled pain, repeat cystoscopy was performed, now revealing scrotal edema and urethral invasion. In an effort to achieve symptomatic relief, elective penectomy with perineal urethrostomy was performed. Pathology again confirmed papillary renal cell carcinoma with sarcomatoid differentiation. His post-operative course

was unfortunately complicated by perineal infection. He ultimately returned to the ED with dyspnea 5 weeks later succumbing to a pulmonary embolism. Discussion: Secondary penile cancer is uncommon despite a rich lymphatic and vascular network supplying that area. It’s important to note that penile injury may be a precipitant of an existing aggressive primary malignancy. Although bladder and prostate cancers are the most likely to result in penile metastasis, renal cancer, especially with sarcomatoid differentiation, should also be considered. This case illustrates the need to consider uncommon primary neoplasms in patients presenting with genitourinary symptoms, and especially those with an aggressive primary, irrespective of epidemiological risk. It also raises the question of the possible need for earlier renal cancer carcinoma screening given the potentially lethal outcomes if diagnosis is delayed.

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123 2025 Research Recognition Day