Louisiana Via Research Day Book 2026

Case Studies: Section 1

Case Studies: Section 1

Catelyn Swenson, OMS-II, Meagan Bickmann, OMS-II; Stephanie Aldret, DO VCOM-Louisiana 43 MANAGEMENT OF FRIEDBERG INFARCTION IN A COLLEGE WATER-SKI ATHLETE

Russel T. Wagner, OMS-I 1,2 ; Hannah L. Walsh, BS 1 ; Aidan E. Boriack, OMS-I 2 ; Traeton Saint, OMS-I 2 ; George C. Bobustuc, MD 1 ; Sammy Khalili, MD 1 ; Neil S. Mundi, MD 1 1 Intent Medical Group, Northwest Community Hospital, Arlington Heights, Illinois; 2 VCOM-Louisiana 44 MARKED CLINICAL AND SEROLOGIC IMPROVEMENT AFTER LINGUAL TONSILLECTOMY FOR REFRACTORY PANDAS

Context: Friedberg Infraction is a rare condition characterized by osteonecrosis of the 2nd metatarsal head resulting in pain, decreased range of motion, and progressive arthritic complications. This disease is thought to be a result of repetitive microtrauma and compromised blood flow to the metatarsal head. Friedberg infraction is mostly diagnosed in adolescent female dancers and tennis athletes. Report of Case: A 21-year-old female Division I collegiate water ski athlete presented with gradual onset of pain and cramping localized near her left 2nd metatarsal. She reported decreased range of motion and clicking of the metatarsal upon movement. Her left foot was mildly tender with palpation and range of motion of her 2nd metatarsal. Metatarsal heads were in appropriate alignment with mild midfoot restriction. Tuning fork testing and Mulder’s Click were negative. Initial portable x-rays showed a slight flattening of the 2nd metatarsal head. OMT, anti-inflammatories, and generic insoles were not helping any longer. After two years of progressive symptoms, she sought formal evaluation. X-rays demonstrated a flattened caput and subchondral clearing

of the 2nd metatarsal phalangeal joint, and MRI of the left foot showed a low signal lesion and bone marrow edema, consistent with Friedberg Infraction. Initial conservative treatment with crutches and insoles provided limited symptomatic relief. Intra-articular steroid injection reduced her pain significantly, allowing her to complete her water ski season. Surgical intervention is anticipated for definitive treatment due to the ongoing symptoms impeding her daily activities. clinical case is consistent with previously published literature on Friedberg Infraction. Literature discusses cases of Friedberg Infraction mostly in tennis players and dancers in contrast to this case of a water-ski athlete. Microtrauma and disruption of blood flow have been discussed as the most likely etiologies, which is consistent with this case, as water ski athletes are exposed to repetitive trauma from jumping and water-ski footwear—specifically the bindings. Diagnostic imaging findings are also consistent with similar case studies with flattening of the metatarsal head and Conclusions: The presentation, diagnostic findings, and treatment approach in the patient’s

bone marrow edema. All literature agrees that surgical intervention is the definitive treatment for Friedberg Infraction, while conservative treatment only stops progression of the disease and helps to continue athletes’ careers. The most common conservative treatments discussed in literature are anti-inflammatory medications, shoe insoles, and injections, in which the steroid injection provided this patient with maximal relief compared to other conservative treatments.

Context: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS) is characterized by abrupt-onset obsessive compulsive disorder (OCD), tics, and related neuropsychiatric symptoms triggered by Group A Streptococcus (GAS) infections. The pathogenesis is thought to involve post streptococcal autoimmune mechanisms targeting basal ganglia circuitry. Palatine tonsillectomy and adenoidectomy have been proposed for refractory PANDAS, with some case series reporting symptom improvement. Lingual tonsillectomy has not previously been reported as a treatment for PANDAS. Clinical Presentation: We describe a 29-year old male with adolescent-onset PANDAS, who presented with severe obsessive-compulsive behaviors, coprolalia, emotional lability, and choreiform movements. His symptoms began at age 17 following a streptococcal infection, with episodic exacerbations that closely mirrored spikes in anti-streptolysin O (ASO) titers. He had previously undergone palatine tonsillectomy in childhood for unrelated indications. Despite subsequent immunomodulatory therapy

(rituximab and maintenance plasmapheresis) his symptoms remained refractory. On otolaryngologic evaluation, hypertrophied lingual tonsils were identified. He underwent bilateral transoral robotic-assisted lingual tonsillectomy, with histopathology revealing dense lymphoid hyperplasia and reactive germinal centers. Postoperatively, ASO titers normalized over several weeks and the patient experienced marked improvement in compulsive behaviors, tics, and attention. Conclusions: This case illustrates dramatic clinical and serologic improvement in a refractory PANDAS patient following lingual tonsillectomy. Lingual tonsillar tissue may have served as a persistent immune reservoir in this patient. While palatine tonsillectomy and adenoidectomy have shown benefit in some PANDAS cases, this is the first report involving lingual tonsil resection to our knowledge. Further study is warranted to clarify indications for surgical removal of tonsillar tissues beyond the palatine-adenoid complex in PANDAS.

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2026 Research Recognition Day