Louisiana Via Research Day Book 2026

Case Studies: Section 2

Case Studies: Section 2

Sundal Aziz, MD; Dirgha Patel, MD; Sahibzada Muhammad Qasim, MD; Harikrishna Bandla, MD Department of Internal Medicine, St. Francis Medical Center 90 UNMASKING THE HIDDEN LYMPHOMA: EPSTEIN–BARR VIRUS (EBV) DRIVEN FOLLICULAR HELPER T-CELL LYMPHOMA PRESENTING AS RECURRENT PLEURAL EFFUSIONS AND INTERSTITIAL PNEUMONIA.

Sundal Aziz, MD; Jeni Kendal, MD; Hasnan Arshad, MD; Khawar Khurshid, MD; Navin Ramlal, MD Department of Internal Medicine, St. Francis Medical Center 91 SEPSIS SECONDARY TO URINARY SOURCE DUE TO KLUYVERA ASCORBATA IN AN ELDERLY FEMALE WITH MULTIPLE COMORBIDITIES

Context: Follicular helper T-cell (TFH) lymphoma is a rare subtype of peripheral T-cell lymphoma characterized by proliferation of mature T cells with a follicular helper phenotype. It commonly presents with generalized lymphadenopathy and extranodal disease but may mimic infectious or autoimmune conditions, delaying diagnosis.1-3 We report an uncommon case of Epstein–Barr virus (EBV) driven TFH lymphoma, follicular type, presenting with recurrent pleural effusions and interstitial pneumonia in a previously healthy young adult. Report of Case: A 28-year-old African American man with no prior medical history presented with persistent epigastric pain unresponsive to proton pump inhibitors, along with weeks of nonproductive cough, dyspnea, and night sweats. He denied fever, weight loss, or gastrointestinal bleeding. Examination revealed palpable, nontender lymphadenopathy in cervical, submandibular, supraclavicular, and bilateral axillary regions, and decreased breath sounds over the right lung base. Laboratory studies showed elevated inflammatory markers but were otherwise unremarkable. Extensive infectious and autoimmune workup was negative

except for positive EBV serologies and PCR level of 2450 IU/mL. Contrast-enhanced CT showed diffuse thoracic, mesenteric, periportal, and retroperitoneal lymphadenopathy with mild ascites, ground-glass, tree-in-bud opacities with small pleural effusions in lungs. Following cholecystectomy for presumed cholecystitis, gallbladder histopathology revealed atypical lymphoid aggregates. The patient later developed recurrent right pleural effusions requiring thoracentesis, chest tube placement, and pleurodesis; cytology demonstrated atypical lymphocytes. Excisional left axillary lymph node biopsy showed effacement of architecture by atypical lymphocytes positive for CD3, CD4, CD5, and CD7, with aberrant CD10 and PD-1 expression. Flow cytometry revealed an abnormal T-cell population lacking surface CD3, and EBV-encoded RNA in situ hybridization showed scattered positive cells. Correlating findings confirmed follicular helper T-cell lymphoma, follicular type. His interstitial pulmonary findings and recurrent effusions were attributed to extranodal involvement. The patient was transferred to a tertiary hematology center for advanced therapy and bone marrow transplant evaluation.

Conclusion: This case illustrates a rare, potentially EBV-driven TFH lymphoma in a young, otherwise healthy patient.4-6 Its atypical pulmonary presentation and recurrent pleural effusions emphasize the need for early multidisciplinary assessment and tissue diagnosis. Clinicians should consider TFH lymphoma in unexplained lymphadenopathy with pulmonary manifestations to enable timely management and improved outcomes.

Context: Urinary tract infections (UTIs) are common in older adults and may progress to sepsis, especially in patients with multiple comorbidities. While Escherichia coli and Klebsiella species are typical uropathogens, rare organisms such as Kluyvera ascorbata have been increasingly recognized as clinically significant in both immunocompetent and immunocompromised individuals. First identified as a human pathogen in the 1980s, Kluyvera has been implicated in UTIs, bacteremia, and intra-abdominal infections and often demonstrates resistance to ampicillin and early-generation cephalosporins while retaining susceptibility to third-generation cephalosporins, aminoglycosides, and fluoroquinolones. Awareness of this pathogen is limited, and its role in elderly patients with urosepsis warrants further clinical attention. Report of Case: An 84-year-old woman with latent tuberculosis (treated for one month), hypertension, hyperlipidemia, type 2 diabetes mellitus with neuropathy, coronary artery disease status post-PCI, and heart failure with reduced ejection fraction (30%) presented with worsening weakness, debility, and hypotension.

She was febrile (101.2°F), hypotensive (110/44 mmHg), lethargic, and minimally responsive. Laboratory evaluation showed metabolic acidosis (bicarbonate 17 mmol/L), BUN 76 mg/dL, creatinine 1.59 mg/dL, albumin 2.5 g/ dL, platelets 68 × 10 9 /L, and CRP 61.1 mg/L. Urinalysis demonstrated nitrites, leukocyte esterase, and many bacteria. CT head revealed no acute abnormalities. She was diagnosed with sepsis secondary to UTI and started on intravenous ceftriaxone and fluids. Due to recurrent hypotension and clinical deterioration, antibiotics were escalated to cefepime and vancomycin. Blood cultures were negative, but urine culture grew >100,000 CFU/mL Kluyvera ascorbata. Despite cefepime and metronidazole, she continued to experience intermittent fevers. Based on susceptibility data, therapy was changed to meropenem 1 g every 12 hours for 14 days. She also received isoniazid with pyridoxine for latent TB. Her fever resolved, renal function improved, and repeat urine cultures were sterile. She was discharged in stable condition on hospital day 17.

pathogen capable of causing severe infection in elderly, multimorbid patients. Although rare, Kluyvera species have been documented to cause UTIs and bacteremia, and outcomes depend on timely diagnosis and appropriate antimicrobial therapy. In older adults, symptoms may be nonspecific, making it challenging to distinguish symptomatic UTI from asymptomatic bacteriuria; however, systemic findings such as fever and hemodynamic instability support true infection requiring treatment. Antimicrobial resistance complicates empiric therapy, as Kluyvera often demonstrates resistance to ampicillin and early-generation cephalosporins but susceptibility to later-generation agents and fluoroquinolones. Prognosis in elderly patients with urosepsis depends on comorbidities, pathogen virulence, and early initiation of effective therapy. The significance of identifying uncommon organisms like K. ascorbata, implementing antimicrobial stewardship practices, and remaining vigilant in the management of infections in susceptible older persons is highlighted by this case.

Conclusion: This case highlights K. ascorbata as an uncommon but clinically significant urinary

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2026 Research Recognition Day