Scholar Commons @ Tower Health

Alli, Yeseena, B.S.

Brenan, Kelly, M.D.

Considering the Histologic and Anatomic Features of Pancreatic Heterotopia in Patient 
Disease Manifestation   
 
Introduction: Pancreatic heterotopia (PH) is pancreatic-type tissue developing outside 
the pancreas, commonly the bowel wall. Symptomology in patients depends on the elements of 
the ectopic pancreas present and the anatomic regions of the bowel involved.  Importantly, these 
elements need to be considered in revisiting the patient’s symptoms and prior diagnosis.  Caustic 
substances released by the exocrine pancreatic glands, if present, can cause injury and 
inflammation in the bowel that causes abdominal pain, nausea, and vomiting, mimicking more 
common conditions. This case series of three PH cases illustrated how specific anatomical and 
histological characteristics of the ectopic pancreatic explain the symptomatology of each patient, 
two of whom had been treated for other conditions.  
 
Case Descriptions: In the first case, pancreatic tissue in the serosal of the bowel wall releases 
pancreatic enzymes into the peritoneal space which causes inflammation, adhesions, an adrenal 
abscess, and subsequent jejunal-colonic fistula formation.  This patient had originally been 
diagnosed and treated for Crohn's disease for years and had a history of an adrenal abscess with 
unknown etiology; however, after the resection of the ectopic tissue, the patient had a resolution 
of the symptoms.  The second case demonstrates heterotopic pancreatic tissue extensively 
involved in the jejunal wall with a large ductal conduit opening to the lumen leading to partial 
obstruction and diarrhea. Because the imaging and symptomology suggest infectious 
gastroenteritis, the patient received two months of treatment, without resolution until resection. 
The third case involves tissue without acini which presented symptomatically much later due to 
the lack of caustic substances being released.   
 
Conclusion: Often pancreatic heterotopia is unsuspected clinically. A thorough examination of 
the resected heterotopic pancreatic tissue should be performed as the elements present are 
essential in framing the patients’ prior symptoms and revisiting prior diagnoses.   Anatomical 
and histological features of the PH should be documented in the surgical pathology report, 
including size, areas of bowel wall involved, type of tissue present, and any areas with obvious 
ductal communication with the bowel lumen and adjacent tissues, as these features correlate with 
the likelihood of the pancreatic tissue to have caused the patients symptoms.  
 


English

Considering the Histologic and Anatomic Features of Pancreatic Heterotopia in Patient Disease Manifestation

Singh, Simranpreet

Jyothi Ramachandran Nair, Devi Parvathy

Yousaf, Zohaib

Kausar, Tahminah

Moh\u27d, Hamzah

Introduction: 
A gram-negative bacterium, named Vibrio vulnificus can result in serious infections and 
is the primary cause of mortality related to shellfish in the US. Infections can manifest in 
a spectrum from cellulitis to necrotizing fasciitis and fulminant septicemia [1]. People 
with chronic liver disease and diabetes are at increased risk for complications. 
Case presentation: 
A 57-year-old female with history of type 2 DM presented with right-hand pain and 
swelling along with high-grade fever and chills. She was deboning the spine of catfish, 
when the bone got stuck in her right palm and on trying to pull it out, she sustained a 
puncture wound. Physical exam revealed puncture wound on hypothenar eminence of 
right hand with surrounding erythema and tenderness. She complained of pain with 
active and passive range of motion, without signs of neurovascular compromise. Initial 
laboratory data revealed WBC count of 22,000 cells/microliter, high CRP of 2.82 mg/dl, 
and slightly elevated lactate of 1.5 mmol/L. Right hand x-ray showed soft tissue and 
subcutaneous edema. Blood cultures were obtained, and empiric IV Vancomycin and 
Piperacillin/Tazobactam were started. After 23 hours of incubation, blood cultures 
became positive for gram-negative rods and infectious diseases were consulted. 
Piperacillin/Tazobactam was continued, and Vancomycin was replaced by Doxycycline. 
MRI of hand showed diffuse subcutaneous edema and flexor tenosynovitis. Plastic 
surgery recommended management with IV antibiotics, elevation, and betadine soaks. 
Later, blood cultures finalized as V. Vulnificus. Piperacillin/Tazobactam was transitioned 
to IV ceftriaxone and doxycycline. Pain and swelling decreased and on day 4, she was 
discharged on oral doxycycline to complete 14-days course and had complete 
resolution on discharge follow-up. 
Discussion: 
V. vulnificus infections are mainly caused by consuming contaminated seafood, 
especially raw oysters, or inoculation of skin while handling seafood or exposure of 
broken skin to seawater [2,3]. Literature review revealed only one article with two cases 
of Necrotizing dermatitis from V. vulnificus reported in France [4]. Our case is the first 
reported case of catfish-associated V. vulnificus septicemia resulting from deboning the 
catfish in North America. Early culture and diagnosis are crucial, as such infection can 
rapidly progress to septic shock and death. 


Debone the fish carefully: A case of vibrio vulnificus septicemia

Aldous, Tanner

Almarzooqi, Sarah

Yu, Mingran

Ellis, Jeremy

The Silent Culprit: Factor V Leiden’s Covert Role in Recurrent Miscarriages and 
First-Time Thromboembolism 
Tanner Aldous, MS31; Sarah Almarzooqi1, MS3; Mingran Yu, DO MBA2; Jeremy Ellis, MD2 
1Drexel University College of Medicine 
2Department of Medicine, Tower Health Reading Hospital 
Keywords: thromboembolism, thrombophilia, Factor V Leiden, pulmonary embolism, 
miscarriage 
Introduction:  
Favor V Leiden (FVL) mutation is a leading cause of inherited thrombophilia affecting 1-5% of 
White populations, often manifesting as venous thromboembolism. Rarely does FVL result in 
arterial occlusions or miscarriage. We present a case of FVL associated with high-burden venous 
and arterial clots in a post-menopausal white female. 
Case Description:  
A 66-year-old-female with twelve prior spontaneous abortions and extensive recent vehicle 
travel without history of malignancy, prior thromboembolism, smoking, or hormone 
replacement therapy presented with 1 week of persistent shortness of breath and acute left 
upper extremity pain and numbness, right upper and lower extremity numbness, and bilateral 
lower extremity swelling.  
Examination revealed no tachycardia, tachypnea, or added lung sounds but there was left arm 
pallor and coolness to the touch with diminished pulses. A 12-lead ECG Showed normal sinus 
rhythm with nonspecific T-wave changes. Laboratory evaluation demonstrated a BNP of 258 
pg/mL (0-100), troponin of 0.08 ng/mL (<0.06), and D-dimer, performed given low Wells Score, 
of >= 20.00 ug/mL (<0.5). Chest CTA revealed moderate-to-large volume bilateral pulmonary 
emboli with evidence of right heart strain. Venous ultrasounds showed occlusive bilateral lower 
extremity deep venous thrombi without any occlusion in the upper extremities. Left upper 
extremity arterial duplex showed occlusion of the left axillary and proximal brachial arteries. 
Thrombophilia evaluation did not show Lupus anticoagulant or cardiolipin IgM/IgG or beta-2 
glycoprotein IgM/IgG antibodies, but revealed a heterozygous FVL mutation, R506Q variant. For 
intermediate-risk PE, treatment began with LMWH at 1 mg/kg twice daily with transition to 
apixaban 5 mg twice daily in consultation with Hematology/Oncology and Pulmonology.  
Discussion:  
Inherited thrombophilia is a rare disorder with FVL being the most prevalent. For first-time 
thromboembolism with a provoking factor, hypercoagulability studies are typically not pursued. 
With no clear guidelines for thrombophilia evaluation, this case describes the importance of 
considering it in those with extensive clot burden or arterial thrombi, even with identified 
provoking factor. Complete evaluation includes antiphospholipid antibodies: cardiolipin, beta-2 
glycoprotein, and Lupus anticoagulant, which if performed during the event, should be 
confirmed after resolution. Without any special indications for alternative therapy, DOACs are 
preferred for anticoagulation.  


The Silent Culprit: Factor V Leiden’s Covert Role in Recurrent Miscarriages and First-Time Thromboembolism

Libera, Robert, DO

Lalwani, Ayushi

Hafeez, Hamza

Fraga, Julian Diaz

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Reversible Type 1 Brugada Pattern Induced by 
Mild Hypokalemia
Robert Libera DO1, Devi Parvathy Jyothi Ramachandran Nair MD1, Ayushi Lalwani MD1, Hamza Hafeez MD2, Julian Diaz Fraga MD2
1 Tower Health Reading Hospital: Department of Internal Medicine
2 Tower Health Reading Hospital: Department of Cardiology
Introduction
First described in 1992, Brugada Syndrome (BrS) has 
been well documented with signature features on 
electrocardiogram (ECG) and an association with sudden 
cardiac death (SCD).1 Recognizing the Brugada pattern on 
the (ECG) is imperative for identifying individuals at high 
risk of sudden cardiac death who may have BrS. Several 
exogenous factors can induce a Brugada pattern ECG, 
including hypokalemia. We report the case of a 33-year-
old male patient who presented with mild hypokalemia 
and a reversible type 1 Brugada pattern on ECG.
Case Description
A 33-year-old male of Puerto Rican descent with a past 
medical history significant for human immunodeficiency 
virus (HIV) and chronic diarrhea presented to the 
emergency department for evaluation of worsening 
diarrhea.  
When the patient presented to the hospital, he was 
afebrile and hemodynamically stable.  Notable laboratory 
investigations revealed potassium 3.1 mEq/L, sodium 132 
mmol/L, chronic pancytopenia, troponin less than 0.03 
ng/mL, sedimentation rate 68 mm/hr, C-reactive protein 
20 mg/L. Stool studies revealed multiple infectious 
pathogens including enteropathogenic E. coli, Norovirus, 
Shigella/Enteroinvasive E. coli. 
ECG was obtained in the ED for evaluation of abdominal 
pain. Patient's initial ECG revealed coved ST elevation and 
T-wave inversions in leads V1 and V2 (Figure 1). Following 
replacement, his potassium improved to 3.5 mEq/L at 
which time a second ECG was obtained (Figure 2). 
Cardiology service was consulted for an abnormal ECG. 
The patient denied any history of chest pain, palpitations, 
exertional dyspnea, or syncope. The patient described a 
concerning family history including a brother who 
reportedly died of cardiac causes at age 44. 
Key Points
• Hypokalemia can induce the Brugada 
pattern on ECG
• While hypokalemia is a known precipitant 
of brugada pattern, this case reports a 
lower threshold of hypokalemia than 
previously known, 3.1mEq/L
• Physicians may engage in shared decision 
making with patients to pursue further 
testing for Brugada syndrome when 
confronted with a Brugada pattern ECG
References:
1. Antzelevitch, Charles et al. “Brugada syndrome: report of the second consensus conference: 
endorsed by the Heart Rhythm Society and the European Heart Rhythm Association.” Circulation 
vol. 111,5 (2005): 659-70. doi:10.1161/01.CIR.0000152479.54298.51
2. Swe T, Dogar MH. Type 1 Brugada pattern electrocardiogram induced by hypokalemia. J Family 
Med Prim Care. 2016;5(3):709-711. doi:10.4103/2249-4863.197295
3.Genaro NR, Anselm DD, Cervino N, et al. Brugada phenocopy clinical reproducibility 
demonstrated by recurrent hypokalemia. Ann Noninvasive Electrocardiol. 2014;19(4):387-390. 
doi:10.1111/anec.12101
4.Notarstefano P, Pratola C, Toselli T, Ferrari R. Atrial fibrillation and recurrent ventricular fibrillation 
during hypokalemia in Brugada syndrome. Pacing Clin Electrophysiol. 2005;28(12):1350-1353. 
doi:10.1111/j.1540-8159.2005.00277.x
5.Nakashima T, Nagase M, Shibahara T, et al. True Brugada syndrome ECG or Brugada phenocopy 
ECG? Can the ECG itself tell us the diagnosis?. J Electrocardiol. 2022;73:59-61. 
doi:10.1016/j.jelectrocard.2022.05.009
Discussion
Figure 1. ECG demonstrating type 1 Brugada pattern in the 
setting of hypokalemia, potassium level of 3.1 mEq/L.
Figure 2. ECG demonstrating improvement of type 1 
Brugada pattern after potassium replacement with serum 
level 3.5 mEq/L.
This case provides support for hypokalemia as an inducer of a 
type 1 Brugada pattern on ECG. Hypokalemia has been 
described in several reports to serve as a substrate for the 
Brugada pattern. Potassium levels at which the Brugada 
pattern was revealed ranged from 1.5 mEq/L- 2.9 mEq/L.2-5 The 
exact threshold of hypokalemia for inducing the Brugada 
pattern is unclear. Our report demonstrates a mild threshold of 
hypokalemia, 3.1 mEq/L, which induced a type 1 Brugada 
pattern on ECG.  Cardiology advised outpatient follow up for 
consideration of genetic testing or pharmacologic testing to 
assess for Brugada syndrome.


Reversible Type 1 Brugada Pattern Induced by Mild Hypokalemia

Ajeya, Deeksha

Henstenburg, Jule Anne

Introduction: The Metropolitan Area Neighborhood Nutrition Alliance (MANNA) provides 
medically tailored meals (MTMs) to individuals with serious illness and related nutritional risk. 
The goal of this research was to determine the effect of MTMs on physical health among clients 
with cancer diagnoses. 
 
Methods: Demographic and pre-post health survey data were extracted via chart review. 
Variables including age, gender, ethnicity, BMI, cancer type, risk of malnutrition (Malnutrition 
Screening Tool, MST) and risk of food insecurity (Hunger Vital Sign™) were measured at 
program intake and their impact on change in pre-post program physical health (PROMIS global 
health – Physical 2a) was assessed using ANOVA. 
 
Results:  The sample was 59% female, mean age 66, and 52% Black and 6% Hispanic. Fifty-
four percent of clients had food insecurity risk and 2/3 had malnutrition risk. On-third had 
normal BMI measures. Three-fourths of clients were in either poor health (39%) or fair health 
(38%) at program start. Age (65+) and risk of malnutrition were the strongest predictors of low 
health scores. Food insecurity and BMI were also significant, while race and gender were not. 
Change in PROMIS T-score was significantly associated with physical health category (poor, 
fair, good, or very good) at program start (p<.001), but not associated with any other co-variates, 
including cancer type (breast, lung, colon, and prostate). Based on mean change in pre and post 
PROMIS scores, those who started in poor health improved (+2) and those who started in good 
or very good health declined (-6, clinically significant).  
 
Conclusion: Physical health category at program start was significantly associated with change 
in physical health during MANNA’s program. The PROMIS questionnaire is self-reported so 
may be subjective to the individual’s perception of physical health. The progression and 
treatment of cancer is also dependent on other medical and social variables that were not 
considered in this study however they may have had different impacts on clients in poor vs good 
physical health categories. Although nutrition plays a role in overall physical health, it is only 
one of many adjunctive therapies in the management of cancer.  


Effect of Medically Tailored Meals on the Physical Health of Patients with a Cancer Diagnosis

Ignatz, Christopher

Young, David, DO

Chwiecko, Brian, MD

Author names: Ignatz, CM; Chwiecko, BS; Young, DC 
Title:  Hiding in Plain Sight; Dermatologic Manifestation of a Systemic Disease 
Keywords: Sarcoidosis, Dermatologic Manifestation, Non-caseating, Granuloma  
Abstract: 
Introduction: Systemic diseases manifest numerous ways. One disease that can affect numerous organ 
systems is sarcoidosis. Although it is associated with pulmonary disease, dermatologic manifestations 
also occur and can be helpful in supporting or identifying the diagnosis. Up to 98% of cases of 
sarcoidosis have lung involvement, but only approximately a third of cases involve the skin.1,2  
Case Description: A 22 year-old Caucasian male presented to the emergency department for evaluation 
of progressive skin lesions that were pustular in nature. He had first noted these approximately 2 
months prior to presentation. Previous workup was unrevealing and patient was given course of 
antibiotics. Despite taking the antibiotics, the lesions persisted and he developed additional skin lesions. 
There was concern for immunosuppressive state due to social factors. However, HIV and 
immunoglobulin testing was negative. Imaging of the chest demonstrated diffuse bilateral reticular 
nodular lesions with mediastinal and hilar adenopathy.  
The patient was admitted to the hospital and started on antibiotics. Infectious disease and pulmonary 
medicine were consulted. Patient underwent extensive infectious workup which was unrevealing. He 
underwent biopsy of skin lesions and pulmonary nodules/lymph nodes. These demonstrated non-
caseating granulomas. The clinical history couple with the histopathology from biopsies and elevated 
ACE level indicated the diagnosis of sarcoidosis with dermatological manifestations. Due to the presence 
of and nonhealing nature of the skin lesions, the patient was subsequently started on a course of 
prednisone with ongoing outpatient follow-up.  
Discussion: This case highlights an uncommon manifestation of a systemic disease. Sarcoidosis if often 
associated with pulmonary disease, however, it can affect all organ systems. Dermatologic 
manifestations can be one of the first concerns of a patient. Thorough history to exclude other disease 
processes. If pulmonary symptoms or abnormalities on radiographs exist, biopsy of either skin or 
pulmonary lesions can be sought to obtain diagnosis. Once a diagnosis is made, treatment—usually with 
systemic glucocorticoids—can be initiated assuming patients are symptomatic. Further montitoring with 
pulmonary function testing and ophthalmologic examinations should also be sought after establishing 
the diagnosis of sarcoidosis.  
References: 
1. Katta, Rajani. Cutaneous Sarcoidosis: A Dermatologic Masquerader. Am Fam Physician. 
2002;65(8):1581-1585. https://www.aafp.org/pubs/afp/issues/2002/0415/p1581.html#:~:text=1-
,Diagnosis,may%20occur%20without%20systemic%20involvement.&text=Because%20lesions%20assum
e%20a%20vast,%E2%80%9Cgreat%20imitators%E2%80%9D%20in%20dermatology. 
2. Te, Hok Sreng et al. Clinical characteristics and organ system involvement in sarcoidosis: comparison 
of the University of Minnesota Cohort with other cohorts. BMC Pulm Med. 2020; 20: 155.  
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268634/ 


Hiding in Plain Sight; Dermatologic Manifestation of a Systemic Disease

Arshoun, Angelica

Jasper, Adam

D\u27Amico, Ella

Yeh, Frank

Erickson, Kirk

Sahu, Amrita

Ambrosio, Fabrisia

Mapping the Maze of Time: Unraveling Chronological Age-Induced Structural
Transformations in the C57BL6 Mouse Brain
Authors:
Angelica Arshoun* M.S., Adam Jasper* B.S., Ella D'Amico M.D., Frank Yeh M.D. PhD., Kirk
Erikson PhD, Amrita Sahu PhD, Fabrisia Ambrosio PhD
*Co-first author
A comprehensive investigation of temporal alterations in neuronal structures can further our
understanding of natural age-associated changes in neuronal function. While efforts are underway to
curate mesoscopic connectomic databases describing natural and pathologic structural alterations in
humans, to our knowledge, no equivalent measures have been comprehensively pursued in mice. To
better define age-related disease-independent changes in a murine model, we used a multimodal
approach via Diffusion Tensor Imaging and a powerful analyzation software [DSI Studio] in young and
old ex vivo C57BL6 mice brains (n=4/age group) segmented into 12 areas and 356 subregions. In
addition to volumetric comparison, age-related changes in white matter integrity were assessed via two
anisotropic measures, and the impact of such changes on neural networks were calculated via network
analysis. Consistent with human findings, we observed volumetric decreases in cortical and
hippocampal areas in aged mice compared to young controls. However, we observed age-related
increases in brainstem nuclear volumes—findings not previously shown in humans. Next, to assess
white matter axonal integrity, we quantified anisotropic measures where decreased fractional
anisotropy and increased quantitative anisotropy suggest worsening integrity. Indeed, as seen in
humans, we observed both decreases in fractional anisotropy and increases in quantitative anisotropy
with increasing age in the hippocampus, cortex, and associated fiber tracks bilaterally. Furthermore,
aging-associated decreases in all network measures revealed compromised neural communication
patterns and deleterious changes in information processing efficiency within 61 brain regions and all 12
areas. These groundbreaking findings unveil that structural age-related neuronal changes in mice mirror
those in humans while simultaneously illuminating the anisotropic and network-driven aspects of
age-related cognitive and behavioral changes.



Mapping the Maze of Time: Unraveling Chronological Age-Induced Structural Transformations in the C57BL6 Mouse Brain

Hariharan, Abishek, MD

Lalwani, Ayushi, MD

Yu, Mingran, DO

Khan, Sara, MD

Atypical presenta.on of Coxsackie B induced viral myocardi.s 
 
Introduc.on: 
Myocardi+s is a disease with a variable clinical presenta+on, ranging from asymptoma+c to a fatal 
outcome. We present this case of a 51 year old male who had a non-specific ini+al presenta+on of a 
viral prodrome and was eventually found to have new onset cardiomyopathy secondary to coxsackie 
B infec+on. 
Case Presenta.on: 
51-year-old man with a history of hypertension presented with 4 days of fevers, chills, diarrhea, 
fa+gue, and loss of appe+te. Ini+al vital signs included a fever of 102.9 F and tachycardia of 115 
beats/min. Laboratory tes+ng was significant for elevated alkaline phosphatase 325IU/L, AST 
347IU/L, ALT 617IU/L, total bilirubin 1.4mg/dL. A CBC was within normal limits but ferri+n was 
2,043ng/mL, ESR 83mm/hr and CRP 30.5mg/dL. Ini+al exam did not reveal any abnormali+es while a 
CT abdomen showed possible enteri+s and mild upper retroperitoneal adenopathy.  
The pa+ent was started on broad spectrum an+bio+cs for treatment of sepsis of unclear e+ology. He 
con+nued to have persistent fevers and extensive work up was done for infec+ous, hematologic, and 
autoimmune causes. Infec+ous workup included nega+ve blood cultures, urinalysis, respiratory viral 
panel, GI pathogen panel, C. difficile, +ck-borne serologies and blood parasite smear. There was also 
concern for viral myocardi+s due to new onset cardiomyopathy revealing an ejec+on frac+on of 47% 
with abnormal septal mo+on. Viral tes+ng for human herpes virus 6, coxsackie and parvovirus B12 
were pending.  
Tes+ng was nega+ve for hematological causes including hemophagocy+c lymphohis+ocytosis, 
lymphoma and mul+ple myeloma. Further blood work revealed a weakly posi+ve ANA 1:80 but 
nega+ve SS-A, SS-B, an+-smooth muscle, an+-double-stranded DNA and rheumatoid factor.  
His fevers eventually resolved spontaneously. Daily clinical improvements were seen and the pa+ent 
was eventually discharged without a clear diagnosis for his fever of unknown origin. However, tes+ng 
for coxsackie B an+body eventually returned posi+ve confirming the diagnosis.  
 
Discussion: 
 
Myopericardi+s secondary to Coxsackie viruses has been reported o`en, however mul+-organ 
involvement is rare. Although the mechanism is not clearly understood, it is thought to involve direct 
viral cytotoxicity as well as immune-mediated damage. A high index of suspicion is warranted for 
viral as well as +ck borne causes of myopericardi+s.  
 
 


An Atypical Presentation of Coxsackie B-induced Viral Myocarditis

Abu Tineh, Mohammad

Tran, Tan

Danishwar, Mahmood

Bukhari, Raesham

Rettew, Andrew

Title: Lymphoma Revealed: Exploring Stroke-Like Patterns 
 
Authors: Abu-Tineh, Mohammad; Tran, Tan; Danishwar, Mahmood; Bukhari, Raesham; Rettew, 
Andrew 
   
Keywords: Paraneoplastic syndrome, Hodgkin lymphoma, Stroke-like symptoms 
 
Word count: 302 
 
Introduction: 
For patients with stroke-like symptoms, a comprehensive diagnostic approach is crucial. We 
report a case of paraneoplastic cerebellar degeneration syndrome secondary to classic Hodgkin 
lymphoma, initially mimicking a stroke. This highlights the importance of a broad diagnostic 
perspective, including consideration of other rare differentials. 
   
 
Case Description: 
A 49-year-old male with anxiety and chronic back pain presented with nausea, vomiting, vertigo, 
diplopia, dysarthria, and gait instability. On the exam, vertical nystagmus was noted. The initial 
impression was a possible acute cerebrovascular accident; hence, a stroke workup, including 
an MRI of the brain was done, which came back negative. Further imaging and infectious 
workup were negative. CSF analysis showed elevated Beta-2 microglobulin, lymphocytic 
predominance, and normal flow cytometry. IV methylprednisolone was trialed for suspected 
immune dysfunction but discontinued due to worsening symptoms. After ten days with no 
improvement, the patient was transferred to higher-level care. PETCT confirmed hypermetabolic 
right cervical lymph node and parotid gland uptake. The paraneoplastic panel was positive for 
anti-trotter antibodies. An excisional biopsy revealed mixed cellularity classical Hodgkin 
lymphoma. The patient was subsequently started on Adriamycin, bleomycin, Vinblastine, and 
Dacarbazine chemotherapy. During the oncology and neurology outpatient follow-up, patient 
reported some improvements with the chemotherapy regimen. 
   
Discussion: 
This emblematic case of paraneoplastic syndromes underlines the diagnostic challenges when 
mimicking stroke-like symptoms. Interdisciplinary collaboration between neurology and oncology 
is pivotal for accurate diagnoses and tailored treatments. Clinicians must maintain a broad 
diagnostic scope to avoid overlooking rare malignancies linked to paraneoplastic syndromes. 
Other potential differentials include autoimmune encephalitis, CNS vasculitis, and infectious 
causes. This emphasizes the need for heightened clinical suspicion in atypical neurological 
presentations, ensuring a thorough exploration of potential underlying conditions. 
  
  


Lymphoma Revealed: Exploring Stroke-Like Patterns

Beauchamp, Saritha

Chern, Irene

Souder, Emily

Chronic Pneumonia in a 1-year-old Male 
Saritha Beauchamp, MD; Irene Chern, MD; and Emily Souder, MD  
Introduction: The differential diagnosis for chronic pneumonia in an infant includes congenital 
anatomical lung abnormalities, infectious etiologies, and respiratory function or immune system 
disorders. In this case report we describe the diagnostic approach to chronic pneumonia in infancy 
through the case of a 1-year-old male found to have disseminated tuberculosis.  
Case Description: A 12-month-old male was admitted to the pediatrics service for pneumonia. Patient 
was born at 37-weeks and birth course was complicated by congenital syphilis requiring a 10-day NICU 
stay. Patient was first noted to have presumed bacterial pneumonia at 8 months of age and was treated 
with multiple courses of antibiotics (cefdinir, amoxicillin-clavulanate, clindamycin) with clinical response 
during which fever and cough improved; however, after antibiotic discontinuation symptoms 
reappeared and serial imaging showed persistence of right middle and lower lobe pneumonia.  Patient 
had no additional medical diagnoses, had never travelled outside of the United States, and had no 
known sick contacts. At time of admission patient was febrile with diminished aeration and crackles 
noted over the right middle and lower lobes; the remainder of vitals and physical exam were within 
normal limits. 
The differential diagnosis for the patient included congenital pulmonary airway malformation, 
congenital bronchopulmonary sequestration, cystic fibrosis, primary ciliary dyskinesia, chronic 
granulomatosis disease, Langerhans cell histiocytosis, sarcoidosis, HIV, and tuberculosis. Patient had a 
positive QuantiFERON test and PPD with 20 mm induration. Further imaging to determine the extent of 
organ involvement secondary to patient’s tuberculosis demonstrated chronic necrotizing pneumonia of 
the right middle and lower lobes with nodules in the bilateral upper lobes, retro-aortic and splenic 
lesions, and cervical lymphadenopathy. Patient was started on therapy with rifampin, isoniazid, 
pyrazinamide, and ethambutol. Seven months after starting treatment, the patient has remained 
asymptomatic. 
Discussion: This case demonstrates the critical importance of a thorough work-up including tuberculosis 
testing in infants with chronic or recurrent pneumonia. In some circumstances, tuberculosis can present 
as a lobar pneumonia or with secondary bacterial pneumonia. The patient’s improvement while on 
antibiotics appropriate for community acquired pneumonia obscured the clinical picture, possibly a 
result of treating secondary infections.  


Chronic Pneumonia in a 1-year-old Male

Phoenixville Hospital

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