 Hello, everyone. Hello. We're going to get started here. Welcome everyone to Grand Rounds. We're going to get started just to make sure we have time for everyone to present. Today is another one of our presentations from our medical students. And we really enjoy these presentations and so we're grateful to you medical students for taking the time to do this and to do a good job. Today we have three presenters and so I'm going to be working to kind of keep things moving along to make sure that everyone has time to present. Just to let all of you know the format, what we tell the students, we tell them to take about ten minutes to present and then about five minutes for questions and discussion, which is really helpful. We really appreciate all of you that participate in that. And then we'll move on to the next person. Because we only have three presenters today, we might have a little more time for discussion with each case. So I'll just kind of move along so don't feel bad if we're moving on without getting to everyone's comments. Today we're starting with David Massop and he's from, so got a little history on him. He grew up in Des Moines, Iowa, went to undergraduate at St. Louis University and then is at Creighton for medical school. Right now he's here working with Dr. Shakur and really enjoying it. And today he's going to be presenting on a sub-retinal mass and immunocompromised patient. Okay, so as he said, my name is David from Creighton presenting retinal mass and immunocompromised patient. Appreciate the opportunity to be here and do this with you guys. So here we go. So a 49-year-old female, she's complaining of a spot in her vision. Spot has been in her left field of vision in the right eye. It began five days ago. It doesn't move. She has no complaints in the left eye. Ten days ago, however, she started developing headaches and a red right eye. She saw her neighbor who's an optometrist and she told us that she had been diagnosed with pink eye. She was placed on dexamethasone, which relieved the red eye and the headache. She then followed up with him again eight days later or two days ago. She was diagnosed with arthritis and switched to pranisalone every one hour. He then saw her again the next day and saw a lesion on the retina. So she was referred to a local retina specialist. Retina specialist saw it and sent it to Moran. So then we kind of pick it up as seeing the patient later that day. So her ocular history, unremarkable. She does have bilateral lacyc. Notably, she has multiple myeloma. It's been in remission for a year. She was diagnosed about five years ago. She had three bone marrow transplants. She also has a central line in place that will come into play a little bit later. She has a couple allergies, no family history. She is on a maintenance chemo of palomalidomite, which is a cousin of palomalidomite. And then dexamethasone to control her multiple myeloma. She's also on prophylactic acyclovir and levothyroxin. No high-risk activity for STDs. Social history. She's at home with her spouse. No cigarettes, tobacco, drugs, or alcohol. She does have an outdoor cat. She does garden. She's outside the U.S. and she has been to states that have various exotic fungi. So her review of systems is grossly negative, except for the headache. That's kind of been on and off. And then the right eye symptoms, which we talked about. So her visual acuity is pretty good in both eyes. Pressure is good. No APDs. She does have a little injection in chemosis. She does have a little cell. She does have some vitritis, but pretty mild. And then on looking at the fundus, there is a lesion inferior temporal adjacent to the macula, but it was a difficult view. So our differential diagnosis at this point is really broad, but infectious and malignancy are pretty concerning, given her history of multiple myeloma and then her semi-immunocompromised state due to the multiple myeloma and then some of the medication. So a tap and inject was performed that day. She got the two antivirals in Klinda, and then the sample was sent to the lab and had the various viruses run on it and then toxo. And then she was told to come back and follow up the next day. We got these pictures the next day. You can see something kind of brewing in the right eye. It doesn't look good. There's a little better picture of it. So you can tell it's a subretinal lesion because the vasculature courses up on top of it. There's Dopplot hemorrhages in it, and then there's also a larger hemorrhage along the inferior border. So here's a montage. It's kind of pretty. So again, the same day we got the pictures. The varicella came back negative. Remaining labs still pending. Started what will become more and more extensive lab workup. Got an MRI that orbit and then scheduled a diagnostic vitrectomy with a subretinal and vitreous biopsies for the following day and then sent her over to the hospital to be admitted by the bone marrow transplant team. But again, her vital signs were stable and her review systems were negative. So she doesn't showcase any systemic infection or anything like that. So here's the MRI we got. There's the mass, intraocular mass you can see in the right eye. And then interestingly, she also has a 7-millimeter ring-enhancing lesion within the left parietal lobe. So she's got two lesions within the CNS system. So then you look downstream, see what's going on in the heart, and then she has this venous catheter that we talked about in her surgical history, and then she also has this irregular mixed-density mass. It's probably a calcified thrombus, but she does kind of have something going on there, so it was a little bit concerning. People were kind of dismissing it, but it was there. So then the next day, she has a partial plane of atrectomy, get the subretinal biopsies and vitreous biopsies, then do an endo laser around the mass to seal it and prevent detachment, and then gas also. And then she got broad coverage for any antimicrobials, amphibank, seph, tazodium, and clinda. And then here's a little video so you can see the diathermy. There's three spots that speak of point field. So here's one, here's two, and here's three, and then he's taking the subretinal aspirate out from underneath, and then he'll go over here to this one. And then here's a lasering around the lesion. Dr. Shakur wanted me to point out how fast he is at this. So, all done. So then we got those samples. We also got blood cultures, and then a spinal tap, and then started heavy-duty empiric treatment. So this is the scorched earth technique. It kind of looks like corona I chose there last weekend. I thought it was kind of cool. So myropenemviraconazole, bank, and sulfidazine and pyromethamine to cover those organisms, according to infectious disease. So post-op, she looked good. Retina was attached. Follow-up, the mask was improving five days out, but the remainder of the exam was unchanged. So we really haven't changed a whole lot other than she's just been getting these antibiotics. In the meanwhile, we tried to figure out what's going on, and we got all these labs, and everything's come back negative. The CRP is slightly elevated at 1.5, but other than that, not too much. So our differential diagnosis is not looking too good right now. It's pretty beat up. So we're still waiting for the PAM PCR to come back, kind of the magic bullet. And at post-op day five, so the same day we looked at the retina and the lesion was improving. Her white count had been trending down. She just had leukopenia. So we stopped all the antibiotics, especially the sulfos can cause leukopenia. She switched to seph and metronitazole. And then to follow up on that, TTE, we got a TEE with a bubble to look for a PFO possible tract from the right side of the heart up to the CNS. But she doesn't have any symptoms of endocarditis. So, again, it's not really fitting the picture. So she's discharged the next day after the TTE on septaraxone and metronitazole. And her first day out of the hospital, we get a call that says it came back positive for nocardia. So nocardia is an aerobic gram positive, weekly acid fast, branching filament is bacteria. It's found in soil. So gardeners would have exposure like our patient, but I think everybody pretty much has exposure. Pulmonary and cerebral infections are the most common, and they need to usually be in an immunocompromised patient, usually more immunocompromised than our patient. Ocular infections are extremely rare. They are usually due to surgical and accidental trauma. You get seeding of the orbit. Cornia is the most common site. And just to show you how rare it is, even with nocardia bacteremia, only 3-5% get a focus in the eye. So treatment. First line is the sulfa. So sulfa dizine, which she was already on. The bolder one she was already on. It's good CNS penetration. Elsewhere in the body, you want to use Bactrim. Then you can see the second lines, including lanazolid, and then muropenum, impenemoseptriaxone, and amicason. Again, the bolder she's already been getting. So when we saw her back and follow up on the lesion had improved, presumably because she was getting 3 antibiotics that worked against it. So there she is. She received those. ID recommended continuing outpatient as septriaxone and lanazolid until her white count increased. Then she could be switched to Bactrim. Imaging. We need to get a CT of the chest to find the source of the lesion. If it's a hematogenous spread, it's most likely in the lungs. And then get an MRI of the brain for follow-up of the abscess to make sure that's improving. So that's all I've got. We're excited. And then thanks to Dr. Shakur and Zimmerman, not for sending me on this trip, but for helping me with this presentation. Any questions? She was on leukovorin, which is not folic acid. It's folinic acid. And that's supposed to help with... How much in specificity? Not off the top of my head, but it's... My understanding of just PCR in general is that if it comes up positive, it's very strong.