Louisiana Via Research Day Book 2026

Case Studies: Section 2

Case Studies: Section 2

Ram Kumar, MD; Mark Megaly, MD; Brittany Clark, MD Internal Medicine Residency Program, Saint Francis Medical Center, Monroe 98 CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS IN AN ELDERLY WOMAN: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE

Tanya Nazar, MD; Parna Pathak, MD; Dirgha Patel, MD; Bikash Poudel, MD Department of Internal Medicine, St. Francis Medical Center 99 MEROPENEM-INDUCED TRANSAMINITIS: A RARE ADVERSE DRUG REACTION

Introduction: Leukocytoclastic vasculitis (LCV) is an uncommon variant of small-vessel vasculitis characterized by immune complex– mediated inflammation of postcapillary venules. LCV can be idiopathic or occur secondary to infections, medications, autoimmune disease or malignancy. The annual incidence is estimated at 4.5 per 100,000 patients per year in the adult population. Here, we present a rare case of cutaneous LCV in a patient without other systemic involvement. Report of Case: A 76-year-old woman with a complex medical history including type II diabetes mellitus, hypertension and chronic kidney disease presented for evaluation of small, red pruritic lesions on her bilateral lower extremities. She reported onset of her rash approximately 1.5 weeks prior., saying that over time they progressed and evolved into painful pustules and vesicles, especially near the ankles. She denied other systemic symptoms or recent medication changes. Physical examination revealed palpable purpura on her shins with additional violaceous vesicles and necrotic bullae near the ankles and feet, sparing the plantar surfaces. Although a

vasculitic process was high on the differential, patient was initiated on PO doxycycline for empiric antibiotic coverage at time for any infectious etiology. Laboratory studies demonstrated mild leukocytosis (WBC 11.4 ×10 9 /L), normal ESR, and mildly elevated CRP (13 mg/L). Blood cultures and HIV screening tests were unremarkable. Except for an elevated rheumatoid factor (50.6 IU/mL), all other autoimmune serologies (including ANA, ANCA, complement levels and cryoglobulins) were within normal limits. Dermatologic biopsy of the affected area was consistent with a diagnosis of leukocytoclastic vasculitis of the small vessels, with perivascular neutrophilic infiltration, leukocytoclasis, fibrinoid necrosis and erythrocyte extravasation in the superficial dermis. She was subsequently prescribed a 14-day course of oral prednisone, after which patient demonstrated marked improvement in pain and pruritus, with complete resolution of her lesions. Conclusion: This case highlights the diagnostic complexity of cutaneous LCV in elderly patients with multiple comorbidities. Early dermatologic evaluation and biopsy are crucial for accurate

diagnosis. For isolated cutaneous disease without systemic involvement, corticosteroid therapy remains an effective treatment for treatment of skin manifestations. Keywords: Leukocytoclastic vasculitis, small vessel vasculitis, prednisone, cutaneous vasculitis, biopsy, elderly.

Background: Meropenem, a broad-spectrum carbapenem antibiotic, is commonly used for the management of severe infections caused by multidrug-resistant gram-negative organisms. Although generally well tolerated, hepatotoxicity can rarely occur from its use, with transient ALT and AST reported in approximately 1-4% of all treated patients. Clinically significant drug induced liver injury (DILI) from meropenem use remains uncommon. Review of literature suggests that although carbapenems are among the top antibiotic classes associated with antibiotic-induced liver injury, with meropenem contributing to approximately 8% of all reported cases. Report of Case: A 68-year-old male with known history of diabetes mellitus complicated by chronic kidney disease and previous urinary tract infections with ESBL E. coli presented Pseudomonas aeruginosa and he was initiated on IV meropenem based on culture sensitivity results. Within the first few days of therapy, serial laboratory testing revealed a marked increase in transaminases, with ALT peaking with confusion, hypotension and a fever. Initial work-up revealed a UTI with ESBL

at approximately twelve times the upper limit of normal and AST at eight times the upper limit of normal, without hyperbilirubinemia. The patient remained asymptomatic during this time. Comprehensive workup excluded alternative etiologies including viral hepatitis (hepatitis A, B, C panels negative), autoimmune hepatitis (negative ANA, ASMA), ischemic or biliary causes. Drug-induced adverse effects were considered after which Meropenem was discontinued. Her LFTs gradually normalized over the next two weeks. Conclusion: Meropenem-associated hepatotoxicity is rare but clinically relevant given extensive use of this medication in management of ESBL, particularly in patients with pre-existing organ dysfunction. DILI can be classified by its clinical presentation (hepatocellular injury, cholestatic injury, or mixed injury), by the mechanism of hepatotoxicity (predictable or idiosyncratic) or the histologic findings (such as hepatitis, cholestasis, and steatosis). Recent randomized clinical data has reported mild, reversible hepatic enzyme elevations in 2-3% of patients receiving meropenem, highlighting the importance of periodic monitoring of liver

function tests during meropenem therapy, particularly in elderly or medically complex individuals. Early recognition of this and immediate discontinuation typically result in full recovery.

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