Louisiana Research Day Program Book 2025

Case Studies: Section 1

Case Studies: Section 1

Alyssa P. VanCardo, OMSIII 1 ; Joseph E. Amarante, MD 2 1 VCOM-Louisiana; 2 Verón Clinic, Verón, Dominican Republic 60 HIV-TB CO-INFECTION TREATMENT LIMITATIONS IN THE RURAL DOMINICAN REPUBLIC: A CASE REPORT

Brett Bell, OMS-III 1 ; Paul Murphy, MD 2 1 VCOM-Louisiana; 2 St. Francis Medical Center 61 METASTATIC RENAL CELL CARCINOMA PRESENTING AS PENILE PAIN – A CASE REPORT

Background: Hispaniola has one the highest prevalence of Human Immunodeficiency Virus Tuberculosis (HIV-TB) co-infection. HIV-TB has a symbiotic pathophysiology increasing complications. The Dominican Republic (DR) faces limitations and differences in treatment of HIV-TB, when compared to developed countries, due to socioeconomic disparities, immigration and rural location. These findings underestimate the importance of utilizing second line treatment plans as cost-effective options, in addition to implementing preventive strategies. A 44-year-old male with no past medical history or medication use presented with severe respiratory distress. He was an immigrant from Haiti. The patient’s language was Creole, requiring a translator to be present. He admitted to alcohol use but denied tobacco and illicit drug use. The patient experienced weight loss, fatigue, fever, shortness of breath, and chest pain. His vital signs were as follows: systolic blood pressure was 140 mmHg, heart rate of 190 beats per minute, respiratory rate of 40 breaths per minute, oxygen saturation of 80%, and temperature of 38.5°C. The patient was cachectic with dry mucous membranes and decreased skin

turgor. He was in acute respiratory distress with retractions. Auscultation demonstrated diffuse bilateral expiratory wheezes. A complete blood count, comprehensive metabolic panel, glucose test, iron panel, sputum sample, and HIV test were ordered; however, lab values were not recorded apart from a hemoglobin of 7 g/dL. The sputum sample indicated TB infection, and the HIV test was positive. Chest X-rays showed blunting of the costophrenic angles with a left sided pleural effusion which obscured the cardiophrenic angles. There are increased lung markings bilaterally as well as left lateral wedging, indicating possible infection or pneumonia. The patient was diagnosed with HIV-TB. The patient was placed on 8 liters nasal cannula with nebulized ipratropium, improving his oxygen saturation to 88%. He was given iron, vitamin C, and vitamin B12 for malnutrition and anemia. One week later, the patient started taking Rifampicin 150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg and Ethambutol Hydrochloride 275 mg. He was also started on Trimethoprim-Sulfamethoxazole 80mg/400mg for opportunistic infection prophylaxis. The patient was not provided antiretroviral medications. He was scheduled

to follow up with a social worker to ensure daily completion of medication via cellular video call. He will continue to visit our clinic as needed throughout his treatment. An underrepresented topic in medical literature is the prevalence of HIV-TB within the DR amongst Haitian immigrants. This case report highlights the aspects that contribute to the growing issue, as observed in our patient. Our patient’s treatment plan had limitations due to poor funding and neglect by the Dominican government and supporting institutions. The differences in HIV TB treatment, immigration bias, political tension, and rural limitations, are issues influencing an increase of HIV-TB. In order to reduce the prevalence of co-infection, surveillance, prevention, and educational strategies are required among rural clinics. On a larger scale, rural communities need increased support from their government and institutional partners. Until support is received, this global issue will remain unaddressed.

Context/Impact: This case is that of a 70-year old male who initially presented with worsening penile pain, which was later determined to be caused by metastatic spread of renal cell carcinoma. This is an extremely rare presentation of this disease with around 30 similar cases being published within the past century and a limited knowledge in best practices regarding treatment. Report of Case: The patient was a 70-year-old male who initially presented to the urology clinic for worsening penile pain and swelling for three days after being struck in the penis by a stick while doing yard work at his home. The patient was sent to the ER for emergent CT of the pelvis, which found peripenile swelling and a partially visualized a cystic and solid mass of the right kidney. A CT of the pelvis was then obtained which found a large heterogenous mass in the midportion of the right kidney concerning for renal cell carcinoma. The patient was then seen by inpatient urology and a subcostal radical nephrectomy was performed. The pathology report confirmed a papillary renal cell carcinoma stage IV (T3aNxM1) and a penile biopsy revealed a poorly differentiated metastatic carcinoma.

The patient then continued to have penile pain so a penectomy with perineal urethrostomy was performed successfully. He then received ten days of radiation therapy for symptomatic control. The patient reported well controlled pain status post penectomy, however at a follow up appointment with urology, he was found to have necrosis of the perineal urethrostomy. He was then taken to the OR for debridement and a suprapubic catheter was placed. During this admission, he was found to have large bilateral DVT’s with only a successful left thrombectomy. Shortly thereafter the patient developed acute respiratory decompensation secondary to a large PE and passed away. Comments/Conclusions: Metastatic spread of any cancer to the penis is a rare occurrence. Typically invasion occurs through retrograde blood flow caused by large regional masses and is typically caused by prostate or bladder cancers. There have only been about 30 cases of metastatic renal cell carcinoma invasion of the penis reported with the past century. Given the rarity of this disease, there is little information on the best treatment protocols, and current treatment is based upon symptomatic control.

However, in all cases of metastasis to the penis, prognosis is poor as this is typically a sign of late stage aggressive cancer. Referencs: Lin YH, Kim JJ, Stein NB, Khera M. Malignant priapism secondary to metastatic prostate cancer: a case report and review of literature. Rev Urol. 2011;13(2):90-4. PMID: 21935340; PMCID: PMC3176556. Cho DY, Kim HJ, Kim JY. Renal Cell Carcinoma Metastasis to the Penis: A Case Report and Literature Review. Medicina (Kaunas). 2024 Mar 29;60(4):554. doi: 10.3390/medicina60040554. PMID: 38674200; PMCID: PMC11052007. Cocci A., Hakenberg O. W., Cai T., Nesi G., Livi L., Detti B., Minervini A., Morelli G., Carini M., Serni S., Gacci M. Prognosis of men with penile metastasis and malignant priapism: a systematic review. Oncotarget. 2018; 9: 2923 2930. Retrieved from https://www.oncotarget. com/article/23366/text/Youssef I, Elst L, Watkin N, de Vries HM, Brouwer O, Protzel C, Ayres B, Albersen M, Spiess PE, Johnstone PAS. International case series of metastasis to penis. BJUI Compass. 2023 Aug 30;5(1):166-169. doi: 10.1002/bco2.282. PMID: 38179026; PMCID: PMC10764158.

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2025 Research Recognition Day