2022 Scholarly Symposium – Medical Management

Aeroccocus urinae is a gram-positive, catalase-negative coccus that is often under-reported due to its misidentification as streptococci or staphylococci, but is a virulent pathogen that can lead to endocarditis. This report details a 67 year old male with complicating factors of previous urinary tract disease and a history of coronary artery bypass graft who had a delay in treatment of aeroccocus urinae leading to endocarditis, urosepsis and ultimately death. In addition to recognizing the virulence of this pathogen, primary care physicians should understand appropriate antibiotic treatment, the common patient population and the risk factors that can help predict severe infection.

For decades, topical retinoids have been widely utilized in the treatment of adult acne vulgaris. These topical medications, such as tretinoin and adapalene, have an attractive efficacy and safety profile that has been extensively documented in the literature. They are well tolerated and may be used long-term to not only address acne, but also to improve the appearance of fine lines/wrinkles, milia, and dark spots. Although topical retinoids are frequently prescribed in the dermatologic care setting, primary care providers may be hesitant to initiate treatment. Often, family physicians prefer to refer adult acne cases to specialty care. This is an option that is entirely appropriate for patients with severe disease, nodulocystic acne, or scarring. However, for a patient with mild-to-moderate inflammatory or comedonal acne, a prescription for a topical retinoid from their primary care provider may be all that is necessary to prevent breakouts and control symptoms. The COVID-19 pandemic has increased the demand for an already overburdened outpatient specialty care system. With the backlog for dermatology appointments in most private practice and academic care centers stretching months to years, it has become more crucial than ever before to triage patients prior to referral. Patients may fail topical retinoid monotherapy with and eventually require more extensive specialty care. However, initiation of first-line retinoids in the primary care setting will increase efficiency of healthcare delivery and offer immediate relief for adult acne patients who face a prolonged waiting period before evaluation by a dermatologist.

A 60-year-old male presented to the clinic for a chronic rash on the penis. The patient reported that the rash resulted in lightening of the skin and nodularity on the glans and shaft of the penis. The rash had been there for a few years and was slowly spreading. It was associated with significant pruritus. The patient also reported discomfort during intercourse. The patient had no personal history of skin cancer.  The patient was circumcised at birth but had no history of other surgical procedures involving the penis. Inspection revealed hypopigmented plaques with thickened areas of scarring on the glans and shaft of the penis. The diagnosis of balanitis xerotica obliterans (BXO), also known as lichen sclerosus of the male genitalia, was confirmed by punch biopsy. BXO is a chronic, progressive, inflammatory dermatitis mediated by lymphocytes with a relapsing remitting course. Prompt and accurate diagnosis of BXO is critical so that these patients can be monitored for potential sequela, including the risk of developing a squamous cell carcinoma within the affected areas. This may arise secondary to chronic inflammation and scarring. The risk of malignancy in patients with BXO is thought to be underestimated but has been quantified in several studies as 2-5.8%. Other adverse outcomes associated with BXO include painful erection, urethral stenosis, and urinary retention. With early intervention topical steroids can reduce disease progression. Regardless of selected treatment modality, patients should be routinely monitored for malignancy and other sequelae and referred to a dermatologist or urologist accordingly.

Purpose – Gender affirming hormone therapy (GAHT) is safe overall, with few adverse effects. One potential adverse effect from using testosterone for GAHT is an increase in hemoglobin and/or hematocrit, known as secondary erythrocytosis. Current guidelines recommend monitoring hemoglobin or hematocrit routinely in the first year, some as frequently as every 3 months, which can create barriers to care. Our study explored the incidence of erythrocytosis in the first year of testosterone therapy among people receiving gender-affirming care.    Methods  This is a descriptive fixed cohort study of hematocrit and hemoglobin data from the charts of 283 people taking testosterone for GAHT.    Results  During the first year of testosterone therapy, the cumulative incidence of hematocrit >50.4% was 3.2%, hematocrit >52% was 1.2%, and hematocrit >54% was 0.07%. All people were taking injectable testosterone cypionate, with a median dose of 100 mg weekly.    Conclusion  Severe erythrocytosis (hematocrit >54%) is a rare outcome of gender affirming testosterone therapy. Clinical recommendations should reconsider the need for frequent erythrocytosis screening within the first year of testosterone therapy for patients who prefer to minimize lab draws.

An adrenal incidentaloma is a mass lesion discovered by radiologic exam. Most frequent hormonal abnormality detected would be the subtle dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Sometimes the incidentaloma secretes sufficient cortisol to suppress ACTH.    A 60-year-old female with PMHx of CKD4, alcohol abuse presented to the ED with right lower extremity cellulitis, flank pain, and two syncopal events prior to arrival. Patient appeared to have volume overload suggestive of acute on chronic diastolic heart failure. Patient’s laboratory findings on admission were significant for hyperkalemia and hyponatremia, raising suspicions for adrenal insufficiency. Her clinical presentation was significant for obesity, buffalo hump, plethora, and “moon facies”, in a setting of borderline type 2 diabetes, suggestive of hypercortisolism. A cortisol level was ordered and was found to be markedly elevated. Both low dose dexamethasone and high dose dexamethasone suppression tests were performed; both tests failed to suppress cortisol levels. ACTH was low consistent of an adrenal source of cortisol. Abdominal and pelvis CT at admission re-demonstrated a previously known right adrenal mass that had increased in size since 2010. Patient reported symptoms of lethargy, abdominal fullness, and weight gain over the past 5 years. This case illustrates the importance of a thorough clinical exam despite the laboratory findings. Although the laboratory findings were suggestive of adrenal insufficiency, clinical presentation pointed towards hypercortisolism.

Atypical hemolytic-uremic syndrome (aHUS) is a rare disease characterized by hemolytic anemia, thrombocytopenia, and acute kidney injury, often leading to uremia.  Unlike its counterpart, shiga toxin producing Escherichia coli HUS (STEC-HUS), it is generally lifelong and debilitating for those diagnosed, often leading to end-organ damage- most commonly renal failure.    We herein report a case of a 33 year old man with a history of hypertension who presented with significantly elevated blood pressure, acute kidney injury (AKI), and thrombotic microangiopathy (TMA). The patient’s clinical condition progressed and he was eventually placed on hemodialysis for renal failure and discharged from the hospital. He had a subsequent admission for a similar scenario in which his blood pressure was once again significantly elevated and he was noted to have labs consistent with TMA. Work-up eventually pointed toward aHUS, and patient was started on a complement component 5 (C5) inhibitor.     Given the difficulty in diagnosis and subsequent increased time to treatment with the effective, but relatively new, C5 inhibitors, it is of the utmost importance to ensure timely recognition and urgent referral or consultation with hematology to start treatment as soon as possible to prevent, or reverse, end-organ damage.